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Background: The internal mammary artery is the vessel of choice for myocardial revascularisation during coronary artery bypass grafting (CABG). Although it is possible to harvest the left internal mammary artery (LIMA) without opening the left pleura, pleurotomy is usually performed to provide adequate exposure and allow the placement of the LIMA medial to the upper lobe, preventing any undue tension on the mammary pedicle. However, the intact pleura technique may have a lower risk of postoperative pulmonary complications. We aimed to study the effects of both procedures on pulmonary function and the incidence of complications., Method: One hundred patients with ischaemic heart disease indicated for CABG were included and divided into two groups. The closed pleural technique group included 50 patients with preservation of the pleural integrity during mammary harvesting. The open pleural procedure group included 50 patients without preservation of pleural integrity. Spirometry was done pre- and postoperatively in both groups and postoperative pulmonary complications in both groups were recorded and analysed., Results: Internal mammary harvesting with preservation of pleural integrity during CABG in patients in the closed pleural procedure group showed significant improvement in forced expiratory volume in the first second (FEV1%), forced vital capacity (FVC%), and FEV1/FVC compared with the corresponding values in patients in the open pleural procedure group, on day 5 postoperatively, at discharge, and at day 30. There were fewer complications in preservation of pleural integrity with regard to lung atelectasis and pleural effusion, which were significantly lower in patients in the open pleural procedure group., Conclusions: Preservation of pleural integrity has beneficial effects on pulmonary function and has fewer associated pulmonary complications., (Copyright © 2019 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Rationale: Although there have been several studies describing clinical and radiographic features about the novel coronavirus (COVID-19) infection, there is a lack of pathologic data conducted on biopsies or autopsies., Patient Concerns: A 56-year-old and a 70-year-old men with fever, cough, and respiratory fatigue were admitted to the intensive care unit and intubated for respiratory distress., Diagnosis: The nasopharyngeal swab was positive for COVID-19 and the chest Computed Tomography (CT) scan showed the presence of peripheral and bilateral ground-glass opacities., Interventions: Both patients developed pneumothoraces after intubation and was managed with chest tube. Due to persistent air leak, thoracoscopies with blebs resection and pleurectomies were performed on 23rd and 16th days from symptoms onset., Outcomes: The procedures were successful with no evidence of postoperative air-leak, with respiratory improvement. Pathological specimens were analyzed with evidence of diffuse alveolar septum disruption, interstitium thickness, and infiltration of inflammatory cells with diffuse endothelial dysfunction and hemorrhagic thrombosis., Lessons: Despite well-known pulmonary damages induced by the COVID-19, the late-phase histological changes include diffused peripheral vessels endothelial hyperplasia, in toto muscular wall thickening, and intravascular hemorrhagic thrombosis.

Background: Postoperative adhesion is one of major concerns at re-thoracotomy. Aspirin has both the anti-platelet and anti-inflammatory effects, and decreases several cytokines production., Objective: We investigated that aspirin could reduce postoperative adhesion formation in a rat model., Methods: We cauterised the lung visceral pleural to make postoperative adhesion in rats. The animals were allocated to a control group and an aspirin administration group (100 mg/kg/day for 14 days). We performed re-thoracotomy and evaluated the adhesion lengths on day 14. We also investigated the cytokine expression in the adhesion region and the peripheral tissue with platelet-derived growth factor (PDGF), platelet-derived growth factor receptor (PDGFR), alpha smooth muscle actin (α-SMA), transforming growth factor beta 1 (TGF-β1), and vascular endothelial growth factor-A (VEGF-A), sequentially., Results: The adhesion lengths were significantly shorter in the aspirin group than that in the control group (8.7±2.0 mm vs 11.2±1.1 mm, p =0.024). The expressions of PDGF and PDGFR were lower in the aspirin group than that in the control group on day 3. The expression of α-SMA on fibroblasts decreased in the aspirin group on day 3. There was no significant difference in the expressions of TGF-β1 and VEGF-A with administration of aspirin., Conclusions: Aspirin could reduce postoperative pleural adhesion by inhibiting the expression of PDGF., Competing Interests: Competing Interests: The authors have declared that no competing interest exists.

Objectives: Resection of tumour spread on a very thin visceral pleura might be challenging, and collateral damage to the lung parenchyma might occur. We aimed to develop an operative technique, which might facilitate the parenchyma-sparing destruction of the visceral pleura. This experimental work investigated the effects of a neodymium:yttrium aluminum garnet (Nd:YAG) laser on the visceral pleura in an ex vivo porcine lung model., Methods: We used a diode-pumped Nd:YAG laser (Limax® 120, KLS Martin, Tuttlingen, Germany) to investigate the effects on the visceral pleural in 20 porcine lungs. The laser was applied on a standardized length in 4 different settings: Group I (80 W, 6 s), Group II (80 W, 12 s), Group III (120 W, 6 s) and Group IV (120 W, 12 s). All specimens were analysed histologically., Results: The mean thickness of the visceral pleura was 81 ± 10 μm. Increasing power levels and longer application duration resulted in significantly enhanced laser destruction effects. The mean depths of the carbonization zone were 142 ± 42 µm, 378 ± 137 µm, 607 ± 155 µm and 1371 ± 271 μm for Groups I-IV, respectively (P < 0.001). The ratio of carbonization zone to pleural thickness was measured for each section (C/P ratio) to quantify the thermal effects. The corresponding C/P ratio for Groups I-IV were 1.72 ± 0.55, 4.98 ± 1.96, 7.11 ± 1.61 and 17.35 ± 4.35, respectively (P < 0.001)., Conclusions: Our study showed that increasing power levels and application duration of the laser lead to a significantly increased carbonization and destruction zones. Further in vivo human studies should evaluate the feasibility of laser application for a potential translational relevance for human use., (© The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: In patients with parapneumonic empyema, decortication is usually preferred to ensure functional lung re-expansion. However, there could be patients exhibiting incomplete postoperative lung expansion and inadequate drainage despite decortication. Therefore, we evaluated factors affecting postoperative lung expansion in patients undergoing decortication., Methods: A total of 221 patients with pyogenic empyema who underwent video-assisted thoracoscopic surgery (VATS) between January and October 2016 in our hospital were reviewed in terms of surgical success. The following factors were evaluated: age; the time between identification of a localized effusion and surgical referral; chest tube drainage durations; any underlying morbidity preoperative blood culture data; and the thickness of the visceral pleura., Results: Several factors that significantly prolonged the postoperative time to lung expansion were evident in patients with diabetes mellitus (DM) and bacteremia; postoperative chest tube drainage was significantly longer in those with DM ( p  = 0.009) and bacteremia ( p  = 0 . 01); and postoperative hospitalization time was significantly longer in patients with bacteremia ( p  = 0 . 01). The thickness of the visceral pleura was strongly correlated with postoperative chest tube drainage duration and postoperative hospitalization time (Pearson correlation coefficient, r  = 0.245, p  = 0 . 00)., Conclusions: In patients with DM, bacteremia, or thickened pleura, the time to lung expansion after operation was longer. Therefore, stricter pre- and post-operative control of blood-sugar levels and adequate antibiotics are required to facilitate postoperative lung re-expansion. In patients with thickened pleurae, prolonged chest tube placement is unavoidable., Competing Interests: The authors have no conflict of interest., (Georg Thieme Verlag KG Stuttgart · New York.)

Objectives: Video-assisted thoracoscopic sublobar resection of ultra-small, non-visible and non-palpable pulmonary lesions is challenging. The purpose of this study was to explore an alternative and efficient method for the localization of pulmonary lesions using electromagnetic navigation bronchoscopy (ENB)., Methods: Between May 2015 and April 2016, 24 consecutive patients with 30 pulmonary peripheral lesions underwent video-assisted thoracoscopic surgery for sublobar resection in our hospital. ENB was performed before surgery to guide a catheter adjacent to the target lesion, and fibrin sealant mixed with methylene blue was injected., Results: All patients underwent ENB with pleural dye marking followed immediately by surgery. No surgical complications occurred. The median size of the nodules was 11.0 mm (range, 6-19 mm). The median navigation time was 18.0 min (range, 13 to 120 min), and the average interval between dye marking and thoracic surgery was 22.1 min (range, 15-40 min). In all cases, the target pulmonary parenchyma was stained and had tactile sense with few complications. All lesions were fully excised, and pathological examination confirmed the accuracy of the dye staining., Conclusions: Fibrin sealant mixed with methylene blue injection with ENB guidance is a new effective approach to localize even ultra-small and non-palpable pulmonary lesions. The visible staining and tactile sensation of this method may allow more rapid intraoperative identification of lesions., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: For primary lung cancer, anatomic pulmonary segmentectomy may have a functional advantage over lobectomy; however, persistent air leak or delayed pneumothorax after segmentectomy is prevalent and increases surgical morbidity. To prevent pulmonary complications after pulmonary segmentectomy, we used 2 methods for the involved intersegmental plane: coverage using polyglycolic acid mesh and fibrin glue (mesh cover) or closing it by suturing the pleural edge (pleural suture). We aimed to compare postoperative pulmonary function and complications between the 2 groups., Methods: A total of 133 patients who underwent pulmonary segmentectomy for stage IA non-small cell lung cancer were analyzed retrospectively. A pulmonary function test, including vital capacity and forced expiratory volume in 1 second, was performed preoperatively and at 1 and 6 months postoperatively. Propensity score analysis generated 2 matched pairs of 46 patients in the pleural suture and mesh cover groups., Results: In each group, there was no significant difference in the recovery rate of vital capacity and forced expiratory volume in 1 second at 1 and 6 months postoperatively. Compared with the pleural suture group, the mesh cover group had higher incidence of prolonged air leak (8.7% versus 0%; p = 0.042), delayed pneumothorax (10.9% versus 2.2%; p = 0.051). On logistic regression analysis, management of intersegmental plane by either mesh cover or pleural suture was the only independent factor related to pulmonary complications (prolonged air leak or delayed pneumothorax) after pulmonary segmentectomy (odds ratio: 5.26, p = 0.047; odds ratio: 13.39, p = 0.018, respectively)., Conclusions: Pleural suturing of the involved intersegmental plane during pulmonary segmentectomy appeared to be an acceptable method to reduce postoperative pulmonary complications., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

In many mammals, including rodents and humans, removal of one lung results in the compensatory growth of the remaining lung; however, the mechanism of compensatory lung growth is unknown. Here, we investigated the changes in morphology and phenotype of pleural cells after pneumonectomy. Between days 1 and 3 after pneumonectomy, cells expressing α-smooth muscle actin (SMA), a cytoplasmic marker of myofibroblasts, were significantly increased in the pleura compared to surgical controls (p < .01). Scanning electron microscopy of the pleural surface 3 days post-pneumonectomy demonstrated regions of the pleura with morphologic features consistent with epithelial-mesenchymal transition (EMT); namely, cells with disrupted intercellular junctions and an acquired mesenchymal (rounded and fusiform) morphotype. To detect the migration of the transitional pleural cells into the lung, a biotin tracer was used to label the pleural mesothelial cells at the time of surgery. By post-operative day 3, image cytometry of post-pneumonectomy subpleural alveoli demonstrated a 40-fold increase in biotin+ cells relative to pneumonectomy-plus-plombage controls (p < .01). Suggesting a similar origin in space and time, the distribution of cells expressing biotin, SMA, or vimentin demonstrated a strong spatial autocorrelation in the subpleural lung (p < .001). We conclude that post-pneumonectomy compensatory lung growth involves EMT with the migration of transitional mesothelial cells into subpleural alveoli.

Background and Objective: Few studies have analysed a large number of patients with necrotizing pneumonia (NP) diagnosed based on computed tomography (CT) scans. The aim of the present study was to document the incidence and clinical features of NP in patients with community-acquired pneumonia (CAP)., Methods: This retrospective study was conducted on CAP patients who had been admitted to a tertiary referral centre and who had available enhanced CT scan images. Patients were allocated into NP and non-NP groups, and they were compared with respect to various clinical variables., Results: Of the 830 patients included in the present study, necrotizing change was observed in 103 patients (12%). Patients with NP experienced more symptoms of pneumonia, had higher blood levels of inflammatory markers and more often required pleural drainage compared to patients with non-NP. Although the use of mechanical ventilation, vasopressor infusion, 30-day mortality, in-hospital mortality and clinical deterioration did not differ between the NP and non-NP groups, the median length of hospital stay (LOS) was significantly longer in the NP group. Multivariate analysis using Cox proportional hazards model showed that necrotizing change independently predicted LOS in patients with CAP., Conclusion: NP affects approximately one-tenth of hospitalized CAP patients. It may be associated with more severe clinical manifestations and may increase the need for pleural drainage. NP was found to be an independent predictor of LOS, but not of mortality in CAP patients., (© 2016 Asian Pacific Society of Respirology.)

Pleuroparenchymal fibroelastosis (PPFE) is a rare progressive disease that manifests as parenchymal fibrosis of the upper lobe and pleura. Approximately 100 cases have been reported. Cutaneous manifestations of PPFE have not previously been described. Diagnosis is dependent on histologic identification of fibrosis with atypical elastic fibers, necessitating an invasive peripheral lung wedge biopsy.A 68-year-old male with a history of pleuroparenchymal fibroelastosis presented with an asymptomatic, telangiectatic erythematous eruption on bilateral lower extremities. Biopsies demonstrated a subtle perivascular infiltrate with marked increase in atypical elastic fibers, similar to the elastosis in the patient's lungs.This is the first documented case of cutaneous manifestations in PPFE. Clinicians need to be aware that cutaneous eruptions clinically simulating telangiectasia macularis eruptiva perstans but lacking a mast cell infiltrate histologically, may have increased abnormal elastic fibers. Thus, early recognition of these lesions in patients with an undefined restrictive lung disorder, may facilitate the diagnosis of PPFE in some patients.

The data, concerning videothoracoscopic operations application in the acute pleural empyema treatment in 462 patients, were adduced. Efficacy of videothoracoscopic operations, using electrowelding and radiofrequency surgical complexes with possibility to eliminate pulmonary-pleural fistulas, was shown. Positive clinical effect was noted in 443 (95.9%) patients, duration of stationary treatment have constituted 11.1 days at average. The complications have had occurred in 19 (4.1%) patients. All the patients are alive.

We herein describe a very rare case of pulmonary hamartoma with pleural dissemination. A 77-year-old male was referred to our department for a further investigation of an abnormal chest radiograph. Chest computed tomography showed a 15 mm nodule in the left lung with small pleural nodules. Thoracoscopic resection of the nodules was performed, as the possibility of malignancy could not be ruled out. The intraoperative findings revealed a white nodule with a lumpy surface in the left lower lobe that had penetrated the visceral pleura. Several smaller nodules were found on the pleural surface. Pathologically, the pulmonary and pleural nodules were chondromatous hamartomas.

Background: Suppurative-destructive diseases of the lung and pleura are prevalent kind of diseases occurring in children. They represent 9.1% of thoracic surgical diseases in this age. In such diseases, the pleural drainage is the most commonly used at present time. One of the methods is the transthoracic drainage by Seldinger., Material and Methods: Over the period of 13 years (2000-2012), 101 children with different forms of acute purulent destructive processes of the lung and pleura were treated in the Department of Pediatric Surgery of the University Hospital "St. George "- Plovdiv. We used percutaneous (transthoracic) drainage (Seldinger method) in the case of three children with lung abscess complicated pleuropneumonia with empyema., Results: We achieved positive effect in treatment with all three children, without introducing additional operating procedures., Conclusion: There is still no consensus regarding the surgical treatment of various forms of acute suppurative-destructive diseases of the lungs and pleura (ASDDLP). Some authors attach great importance to the puncture method of treating ASDDLP, whilst they recommend the application of another treatment in case of failure.

Purpose: Catamenial pneumothorax (CP) is classified as thoracic endometriosis syndrome. There are few reports of CP, and the clinical manifestations of this disease are unclear. The aim of the present study is to clarify the features of CP., Methods: The clinical and pathological files of the 92 female patients pathologically diagnosed with thoracic endometriosis are included in this study. The clinical data and pathological findings of the recurrent and non-recurrent groups are compared., Results: Thirty-six patients (39.1%) experienced recurrence, 37 (40.2%) patients did not, and 19 (20.4) patients could not be evaluated. The ratio of the endometrial gland in the diaphragm is significantly higher in the recurrent cases in comparison to non-recurrent cases (66.7% vs. 37.8%, P = 0.01)., Conclusions: The recurrence rate of CP is high. Further study of the optimal management strategies is needed, especially for CP cases with the endometrial gland in the diaphragm.

We present a case of right pneumonectomy after induction chemotherapy complicated by a large bronchopleural fistula and empyema two weeks after surgery. The patient was treated surgically by transsternal transpericardial bronchopleural fistula closure and open window thoracoplasty. Thereafter, two new fistulae developed, one in the right main bronchial stump and one in the accessory tracheal bronchus. The two Amplatzer devices that were originally designed for transcatheter closure of cardiac defects were successfully used for closure of the bronchopleural fistulae., (Copyright © 2013 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

During 2006-2012 years different types of parietal pleurectomy (PE) with lung decortication (LD) were performed for 135 patients. Among them: 42 (31.1%)--had standart PE with LD (with performing usual thoracotomy); 34 (25.2%)--had video-assisted thoracic surgery (VATS) PE with LD; 36 (26.7%)--videothoracoscopy (VTS) PE with LD; 23 (17.0%)--standart PE with LD combined with lung resection. Common effectiveness of surgical treatment was 96.3%, mortality level--1.5%, postoperative complication level--8.9%. On the early stage of pleural diseases VATS PE with LD and VTS PE with LD are more preferable. To unclear and difficult cases for performing standart PE with LD we consider that operation should begin by VTS pleural space investigation. In some cases minithoracotomy is possible with performing VATS PE with LD or standart PE with LD (performing usual thoracotomy).

Objectives: The role of radical pleurectomy (RP) in the management of IMIG stage III in malignant pleural mesothelioma (MPM) remains controversial. The aim of the study was to investigate the feasibility and outcome as well as to determine factors predicting poor survival., Methods: Patients having IMIG stage III MPM were identified within a prospective multimodality treatment study (RP followed by chemoradiation) between 2002 and 2010 at a single institution. Kaplan-Meier analyses, log-rank test and Cox regression analyses were used to estimate survival and to determine predictors of survival., Results: A total of 78 patients (66.3 ± 2.5 years, 65 males) underwent RP followed by chemoradiation. A total of 42 (54%) had IMIG stage III. Mortality and morbidity were 4.8 and 31%, respectively. Median survival and 5-year survival were 21 months and 28%, respectively, for stage III patients. Progression-free survival was 11 months. The sites of failure were predominantly locoregional (20/42, 47.6%). Pathological detection of tumour spread at the resected thoracoscopy incisions (median survival 12 vs 35 months, P < 0.001), incomplete resections (median survival 13 vs 35 months, P = 0.01) and male gender (median survival 18 vs 68 months, P < 0.039) were associated with inferior survival in the univariate analyses. Histology, lymph node metastases, laterality and age had no significant impact on survival. The tumour spread at the resected previous incisions remained the only significant prognostic factor (hazard ratio (HR) = 4.3; P = 0.027) in the multivariate analysis. Patients having tumour spread had survival comparable to that of patients at stage IV in the complete patient cohort (median survival 12 vs 8 months; P = 0.39)., Conclusions: Lung-sparing RP for IMIG stage III MPM is feasible and offers promising long-term survival. The tumour spread at the resected previous incisions is associated with more incomplete resections and was a negative prognosticator for long-term survival. The tumour spread at the resected previous incisions or chest tube sites should be considered as T4 or stage IV according to the IMIG staging system.

Background: The effect of pleurectomy/decortication or extrapleural pleuropneumonectomy on pulmonary function has not yet been evaluated. The aim of this study was to determine the parameters of pulmonary function before and after pleurectomy/decortication or extrapleural pleuropneumonectomy., Methods: We conducted a review of 48 patients with unilateral malignant pleural mesothelioma who underwent pleurectomy/decortication or extrapleural pleuropneumonectomy. Data including medical history, histology, survival, and pre- and postoperative pulmonary function were extracted from the medical database of the University Medical Center Freiburg, or sought by telephone interview with the general practitioner or patients., Results: 25 patients underwent extrapleural pleuropneumonectomy and 23 had pleurectomy/decortication. Pulmonary function was not significantly reduced in the pleurectomy/decortication group postoperatively. In the extrapleural pleuropneumonectomy group, the median preoperative total lung capacity of 4.8 L (77.7%) differed significantly from the postoperative total lung capacity of 3.5 L (55.3%; p <0.0006). The median vital capacity was significantly reduced from 2.8 L (77.7%) preoperatively to 1.8 L (47.6%) postoperatively (p <0.0002). Other parameters were also highly significantly reduced after extrapleural pleuropneumonectomy., Conclusions: Pleurectomy/decortication preserved good pulmonary function, whereas extrapleural pleuropneumonectomy significantly reduced pulmonary function, which may lead to dyspnea and influence the quality of life of these patients.

A technique for the safe transfer of electric energy to the pulmonary surface for the potential evaporation of malignant tumours is non-existent to date. By conducting the current study, we wanted to generate data on the potential beneficiary effects and complications of using cold-plasma coagulation on the pulmonary surface. Cold-plasma coagulation was applied to the pulmonary surface in eight female mini-pigs via a thoracoscopic access. After 12 days, we performed a re-thoracoscopy on the contralateral side. After a further 12 days, we performed a median sternotomy and did cold-plasma coagulation on previously untreated areas of either lung. No pulmonary fistulas were detected. In two of the eight pigs, we found a localized chronic pneumonia. None of the pigs died during the course of the study. Morbidity was also low with two pigs refusing food intake, one pig with dyspnoea after difficult intubation and one pig coughing. All events were self-limited and occurred only on post-operative Day 1. The treatment effect was almost linear and correlated to the generator energy applied. The differences between the effects reached statistical significance (P < 0.05). The application of cold-plasma coagulation to the pulmonary surface is safe in pigs. A potential clinical application of this technique is treatment of malignant pleural mesothelioma.

Introduction: Data on the feasibility and effects of single lung ventilation (SLV) in children are scarce. We conducted a retrospective study on the feasibility of SLV during video-assisted thoracoscopic surgery (VATS) in children and adolescents undergoing major thoracic procedures., Methods: A retrospective chart review of all records from patients who underwent VATS at our institution from 2000 to 2010 was done. Patients receiving SLV were analysed in detail. Endpoints of the analysis were conversion to open thoracotomy (frequency and reasons), postoperative duration of ventilation, and pulmonary complications such as radiologically confirmed atelectasis and pneumonia., Results: 74 out of 305 patients (24%, 43 boys, 31 girls) with a mean age of 9.4 years (56 days-18 years) and mean weight of 34 kg (4.5-76 kg) had SLV. Lung resection was done in 43 (58%), pleural surgery in 17 (23%), a combination of both in 7 (9%), and mediastinal procedures in 7 (9%). 11 patients (15%) required conversion of VATS to open surgery, mostly because of problems with exposure of the operative field (73%). 32 patients (43%) were extubated immediately after the operation, whereas 8 (11%) required ventilation for more than 24 h. The mean intensive care unit stay was 1.6 days. 18 patients (24%) developed radiologically confirmed atelectasis, and 1 patient (1%) required bronchoscopic clearance. Pneumonia occurred in 1 case (1%) and was successfully treated with antibiotics., Conclusion: SLV is feasible in children and adolescents undergoing VATS for a broad spectrum of procedures. However, despite SLV, the conversion rate in our series was 15%. The main reason for conversion was problems with exposure of the operative field. The complication rate for SLV was low. Atelectasis developed in every fourth patient but usually resolved spontaneously, and intervention to achieve ventilation was rarely indicated., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: Exacerbation of pulmonary dysfunction has been reported in patients receiving a pleural drain inserted through the intercostal space in comparison to patients with an intact pleura undergoing coronary artery bypass grafting (CABG). Evidence suggests that shifting the site of pleural drain insertion to the subxyphoid position minimizes chest wall trauma and preserves respiratory function in the early postoperative period. The aim of this study was to compare the pulmonary function parameters, clinical outcomes, and pain score between patients undergoing pleurotomy with pleural drain placed in the subxyphoid position and patients with intact pleural cavity after off-pump CABG (OPCAB) using left internal thoracic artery (LITA)., Methods: Seventy-one patients were allocated into two groups: I (n = 38 open left pleural cavity and pleural drain inserted in the subxyphoid position); II (n = 33 intact pleural cavity). Pulmonary function tests and clinical parameters were recorded preoperatively and on postoperative days (POD) 1, 3 and 5. Arterial blood gas analysis and shunt fraction were evaluated preoperatively and in POD1. Pain score was assessed on POD1. To monitor pleural effusion and atelectasis chest radiography was performed routinely 1 day before operation and until POD5., Results: In both groups a significant impairment was found in lung function parameters until on POD5. However, no significant difference in forced vital capacity and forced expiratory volume in 1 second were seen between groups. A significant decrease in partial pressure of arterial oxygen and an increase in shunt fraction values were observed on POD1 in both groups, but no statistical difference was found when the groups were compared. Pleural effusion and atelectasis until on POD5 were similar in both groups. There were no statistical differences in pain score, duration of mechanical ventilation and postoperative hospital stay between groups., Conclusion: Subxyphoid insertion of pleural drain provides similar effects to preserved pleural integrity in pulmonary function, clinical outcomes, and thoracic pain after OPCAB. Therefore, our results support the hypothesis that once pleural cavities are incidentally or purposely opened during LITA dissection, subxyphoid placement of the pleural drain is recommended.

Objectives: There is a resurgence of interest in lung-sparing extirpative surgery for malignant pleural mesothelioma with recent reports of better survival and fewer adverse consequences than with extrapleural pneumonectomy. However, these operations are not well-characterized and to offer evidence-based clinical recommendations and to plan future trials a summary of what is already known is required., Design: A formal literature search was performed and all recovered titles were sequentially sifted by title, abstract and full-text reading according to prespecified criteria. Papers were selected if they contained data relevant to the area of enquiry. Quantitative synthesis and textual analysis, appropriate to the material, were performed., Setting: Follow-up studies of patients undergoing surgery for malignant pleural mesothelioma in specialist thoracic or cardiothoracic units., Participants: Among the operated patients described in these papers, a total of 1270 patients had undergone lung-sparing surgery for mesothelioma., Results: There were no randomized trials or other forms of controlled studies. From 464 titles, 26 papers contained sufficient data on 1270 patients to be included in the systematic review. Operative descriptions for all series were extracted and tabulated and variation was found in the nature of surgery within and between series, and the degree of detail with which it was described. There was more operative detail in recent papers. All available numerical data were extracted, tabulated and summarized using quantitative methods. The average survival at 1, 2, 3, 4 and 5 years was 51%, 26%, 16%, 11% and 9%, respectively. There were no data on patients' performance status, symptomatic change, or other patient reported outcomes., Conclusions: In the absence of any form of control data, no conclusions can be drawn concerning survival differences or symptomatic benefits attributable to surgery. As mesothelioma surgery is restricted to a selected minority of patients who often have multiple therapies, future research will require controlled studies with explicit definitions of the clinical and surgical intent.

To determine whether video-assisted thoracoscopic surgery (VATS) is associated with a lower incidence of intrathoracic adhesion after pulmonary resection, we assessed the incidence of adhesion for patients who underwent a second pulmonary resection. The site and extent of adhesion were evaluated by reviewing videotapes recorded during surgery. A significantly (P<0.05) lower rate of mediastinal or interlobar adhesion was observed in patients with pneumothorax (10%) in comparison with lobectomy (57%) or partial resection for tumors (63%), although there were no statistically significant differences in adhesion to the chest wall. There were no significant differences between VATS and thoracotomy for mediastinal or interlobar adhesion. However, a significantly (P<0.05) lower rate of adhesion to the chest wall was observed for VATS (54%) in comparison with thoracotomy (100%). Although VATS resulted in less adhesion to the chest wall than thoracotomy, there was no difference in mediastinal or interlobar adhesion.

Background: This study evaluated the influence of pleurotomy on pulmonary function after off-pump coronary artery bypass grafting (CABG) using the left internal thoracic artery (LITA)., Methods: Thirty patients were prospectively allocated into two groups: 15 patients with an opened left pleural cavity (OP group) and 15 patients with an intact pleural cavity (IP group). Bedside pulmonary function tests were recorded preoperatively and on postoperative days 1, 3, and 5. Arterial blood gas analyses and ratio of partial pressure of arterial oxygen (PaO2/fraction of inspired oxygen (FiO2) ratio were evaluated preoperatively and on postoperative day 1., Results: A significant decrease of pulmonary function was observed in both groups until postoperative day 5. When compared with the percentage of the preoperative value, the forced vital capacity was significantly lower in the OP group than in the IP group on postoperative days 1 (33.3% +/- 8.3% versus 49.1% +/- 8.4%, p < 0.001), 3 (45.4% +/- 7.0% versus 62.1% +/- 8.6%, p < 0.001), and 5 (56.1% +/- 8.7% versus 77.5% +/- 11.6%, p < 0.001). Similar results were found for forced expiratory volume in 1 second on postoperative days 1 (35.7% +/- 8.6% versus 50.0% +/- 9.8%, p < 0.001), 3 (48.4% +/- 7.0% versus 61.5% +/- 9.02%, p < 0.001) and 5 (58.8% +/- 8.5% versus 75.9% +/- 10.2%, p < 0.001). The PaO2 value and the PaO2/FiO2 ratio dropped on postoperative day 1 in both groups (p < 0.05), with a higher fall in the OP group (p < 0.05). Orotracheal intubation time (p = 0.012) and hospital stay (p = 0.002) were lower in the IP group., Conclusions: Off-pump CABG using the LITA, independently of pleural opening, induced a significant reduction in early postoperative pulmonary function. However, the patients undergoing pleurotomy demonstrated more pronounced pulmonary dysfunction.

Background/purpose: Extrapleural pneumonectomy (EPP) is an en bloc resection of the pleura, lung, diaphragm, and pericardium. EPP in the pediatric population has not been reported in the literature. We report our experience of using EPP in children to treat a variety of malignancies that involve the pleural surface., Methods: We performed a retrospective review of all children treated through EPP at our institution. Data were obtained from patient charts and a pediatric database. All patients underwent en bloc resection of the pleura, lung, diaphragm, and pericardium and reconstruction., Results: Four patients underwent EPP from 2000 to 2004 for inflammatory myofibroblastic tumor, spindle cell sarcoma, metastatic neuroblastoma, and malignant mesothelioma. The patients' ages were from 6 to 11 years. The patient with metastatic neuroblastoma had recurrent disease in the left chest 1 year after EPP and died of sepsis; the patient with mesothelioma died of disease extension into the abdomen 1.5 years later. The other 2 patients are free of disease., Conclusions: EPP can be performed with curative intent in selected pediatric patients with pleural-based malignancies. EPP should be included in the armamentarium of the pediatric thoracic surgeon and evaluated in larger studies.

Amnion allografts have been used in a number of clinical applications. However, no references of their use in thoracic surgery have been identified. Air leakage, is one of the most common complications in thoracic surgery, resulting from visceral pleura and lung injuries caused intraoperatively, in particular following rethoracotomy. Mechanical and manual sutures are also potential sites of air leakage. The aim of our study was to evaluate the usefulness of human amnion grafts in the treatment of air leakage following thoracic surgery. Deep-frozen, radiation-sterilized (35 kGy) human amnion grafts prepared in the Central Tissue Bank in Warsaw (Poland) were used. The amnion allografts were applied to 20 patients who had surgery: 11 thoracotomies and 9 rethoracotomies were performed (15 resections of 1-12 metastases, 3 lobectomies and 2 residual tumor resections). During lung ventilation the air leakage sites were covered by the amnion flap attached by moderate compression and stabilized by sutures. Air leakage and drainage were measured during the postoperative period. In 80% of the cases, no traces of air leakage was observed. The preliminary results suggest that the application of human amnion grafts may be a safe and effective method for preventing prolonged air leakage after thoracic surgery.

The concept of separating the pleural cavity to better control residual spaces has been revisited by introducing a technique of pleural partition through transposed chest wall muscles (muscle tent). This technique has been successfully used in 3 patients with severe lung destruction due to chronic infections who required subtotal pulmonary resections.

Introduction: Fifty-eight patients (mean age 27 years, range 17-44) with primary spontaneous pneumothorax (PSP) underwent resection of apical bullae and partial apical pleurectomy via mini-thoracotomy or thoracoscopy, in 12 cases bilaterally, between 1982 and 1999., Method: After a mean follow-up period of 111 (16-212) months, 26 patients with 31 operated lungs were reassessed by high-resolution CT (HRCT) to demonstrate postoperative morphological changes., Results: Neither relevant clinical symptoms nor recurrence of a pneumothorax were found. However, HRCT revealed new apical bleb formations in 22 (71%) of 31 lungs. Neither the surgical approach, the technique of resection nor giving up smoking could be correlated to the tissue alterations. Surgical excision of the apex of the lung does not stop bleb formation., Conclusion: This study confirms earlier results from a different institution, when blebs recurred in 50% of the cases. The presence of these new apical formations neither influenced the clinical outcome nor predisposed to recurrence of PSP. Parietal (partial) pleurectomy seems mandatory to prevent PSP in the long-term.

Three cases of chronic thoracic empyema treated by decortication are reported with special reference to the indications for surgery. The first patient was a 68-year-old man who had right chronic thoracic empyema with a bronchopleural fistula. He underwent open thoracostomy, and decortication was performed after 8 months. The second patient was a 74-year-old man who had right chronic empyema without bronchopleural fistula. Open thoracostomy was also performed and decortication was done after 2 months. Postoperative pulmonary function was significantly improved in both patients. The third patient was a 66-year-old man who had left chronic empyema with a bronchopleural fistula. He underwent open thoracostomy and left lower lobectomy, and then decortication and the omental pedicle flap method were performed after 4 months. All three patients are still doing well currently. It is concluded that decortication significantly improves pulmonary function in properly selected patients, and that computed tomography is helpful for assessing the re-expansion ability of the collapsed lung.

Objective: To determine effects of surgical pleurotomy, continuous positive airway pressure, and fluid balance during cardiopulmonary bypass (CPB) on lung mechanical properties and indices of oxygenation., Design: Prospective, descriptive, and interventional study., Setting: Cardiothoracic service at a major university referral center., Participants: Eighteen anesthetized-paralyzed patients undergoing elective coronary artery bypass grafting requiring CPB., Interventions: During CPB, continuous positive airway pressure (CPAP) was applied to nine patients, in nine others, no CPAP was applied., Measurements and Main Results: From measurements of airway and esophageal pressures and flow, lung resistance and elastance were determined before sternotomy and after sternal reapproximation. Measurements were made during forced ventilation over a physiologic range of tidal volumes and frequencies, and frequency and volume dependences of lung resistance and elastance were additionally identified. In all patients, lung resistance and elastance increased after CPB, consistent with models of pulmonary edema. Multiple regression analysis showed that these increases were relatively less in patients with intact pleurae (p < 0.05) or net negative fluid balance (p < 0.05); however, no difference in these increases was noted between patients receiving CPAP and those receiving no CPAP. Increases in lung resistance were positively correlated to net fluid balance, and negatively correlated to frequency and tidal volume (p < 0.05). Increases in lung elastance were positively correlated to tidal volume (p < 0.05). Absolute change in alveolar-arterial oxygen gradient was negatively correlated with net fluid balance, whereas percentage change was positively correlated to changes in lung elastance (p < 0.05)., Conclusions: These findings suggest that pleurotomy before CPB and positive fluid balance during CPB enhance postbypass pulmonary edema and/or atelectasis, as demonstrated by acute changes in respiratory mechanics and indices of oxygenation. Low levels of CPAP applied during CPB did not significantly change either mechanical properties or oxygenation.

From 1985 to 1994 decortication of the lung was performed in 60 patients. The indications were: specific and non-specific empyema, chronic pleural effusion, chronic pneumothorax and hemothorax. To assess the lung function, the measurements of vital capacity, forced expiratory volume and maximum breathing capacity, as well as blood gas analysis were performed preoperatively and six months after the operation. The slight improvement of lung function was seen postoperatively. Usual postoperative complications were successfully treated. Indications for decortication for the purpose of improving the lung function remain questionable.

Coronary artery by-pass grafting with internal mammary artery (IMA) has become the graft conduit of choice, due to improved survival and its long term patency rate. However, some studies have shown that, in comparison with saphenous vein grafts, after IMA grafting, there is increased postoperative impairment of pulmonary function, possibly due to the frequent performance of pleurotomy. In 57 consecutive patients, admitted for elective CABG with IMA, we prospectively evaluated the early (2nd and 6th day) postoperative chest X-ray complications and the late (2 months) respiratory function tests changes. Thirty-two patients had been subjected to pleurotomy (group 1) and 25 not (group 2). The incidence of pulmonary atelectasis and pleural effusion in 2nd and in 6th postoperative days was not different in the two groups: 22 vs. 19%, 74 vs. 52% in 2nd, and 29 vs. 19%, 48 vs. 38% in 6th postoperative day respectively. The incidence of elevated hemidiaphragm in 6th postoperative day was not different in the two groups (18.5 vs. 14%). Two months after surgery the mean values of spirometric tests were significantly lower than the preoperative values: VC from 88.5 +/- 1.26 to 80 +/- 1.65% of predicted, P < 0.001, FEV1 from 96.1 +/- 1.27 to 84.7 +/- 1.73% of predicted, P < 0.001, MEF50 from 84.9 +/- 3.14 to 69.2 +/- 3.18% of predicted, P < 0.001. No significant changes were detected in RV and in AaPO2.(ABSTRACT TRUNCATED AT 250 WORDS)

We studied the influence of pleurotomy during harvesting IMA for CABG on postoperative pulmonary function. Ninety nine cases underwent CABG surgery from January 1991 to July 1992, were divided into three subgroups, 45 patients (subgroup AY 2) having bilateral IMAs graft with pleurotomy, 45 patients (subgroup AY 1) having unilateral IMA graft with pleurotomy, 9 patients (subgroup AN) having unilateral IMA graft or vein grafts without pleurotomy. Frequencies of chest X-rays abnormality such as elevation of diaphragm and accumulation of pleural effusion before discharge around 2 weeks after surgery, were not significantly different among three subgroups. 58 cases without chest X-rays abnormalities were divided into three subgroups in the same way. There was no case with late extubation or with postoperative pulmonary complication. At first we compared pre-with postoperative pulmonary function in each subgroups. Pulmonary function (VC, FEV1.0, peak flow, MMF, V50, V25) was significantly deteriorated in the patients with pleurotomy, while VC, FEV1.0, peak flow significantly decreased, and MMF, V50 and V25 tended to decrease in the patients without pleurotomy. Moreover, magnitude of change of pulmonary function from pre- to postoperative period were not different significantly among three subgroups. In conclusions pleurotomy itself didn't appear to influence postoperative morbidity.

Pleurectomy as a method for treatment of recurrent pneumothorax and its influence on pulmonary ventilation are analyzed. Fifty-one patients were hospitalised twice at the Thoracic Surgery Department in Szczecin. The pneumothorax was treated by a chest tube drainage at the first time, and by pleurectomy in case of recurrent incident. Each time--with both lungs expanded--VC (vital capacity), MVV (maximal voluntary ventilation) and FEV1 (forced expiratory volume) were measured, thus it was possible to compare pre- and postoperative spirometric results. There was no statistically significant deficiency of ventilation after pleurectomy. The risk of different therapeutical methods and effectiveness in the protection against recurrence of pneumothorax were discussed. The results of own observations are compared with other authors' ones.

Despite appropriate antibiotics and pleural drainage, the condition of some children with empyema fails to improve. In a 5-year period, 10 children ranging in age from 2 to 16 years underwent lung decortication for a refractory, symptomatic empyema, which had developed 3 to 5 weeks after an initial pneumonic infiltrate. Responsible organisms included beta-hemolytic streptococci, Haemophilus influenzae, or Streptococcus pneumoniae in 6 children. Negative cultures were found in 4 children. The initial computed tomographic scan of the chest in 4 of 8 patients showed more than 75% limitation of lung expansion by the contents of the empyema cavity. In 4 other patients, an extensive pleural peel was seen on initial computed tomographic scan of the chest. Several studies also showed cystic lesions in the collapsed lung. Multiple computed tomographic scans in 3 patients confirmed the lack of clinical and chest roentgenographic improvement with conservative therapy. At decortication in each, the visceral and parietal pleural peel was completely removed, freeing the trapped lung. Two patients also had a concomitant lobectomy for a necrotic right upper lobe (1 patient) and left lower lobe (1). Clinical improvement was marked, with return of temperature, white blood cell count, and appetite to normal. Postoperative morbidity was minimal. Analysis of these patients in whom traditional conservative therapy failed suggested that the initial management during the early exudative phase was often delayed and was not aggressive enough from the standpoint of pleural drainage.(ABSTRACT TRUNCATED AT 250 WORDS)

The paper reports on the indications and results obtained, in the study of 224 autonomous or associated pleural pulmonary decortications. The decortication is aimed at removing the chronic pleural sack and the possible parenchymatous lesions and at the recovery of the maximum functional pulmonary parenchyma. For the recently chronic cases, the authors suggest the early surgical indication; the pleural pulmonary decortication is better achieved technically and gives better lesional and functional results if it is made earlier; the optimum operatory moment of the decortication superimposes on the moment of chronicization of the pleural sack (2-6 months). The decortications for chronic pleural tuberculous sacks were followed by good results in 85.72% of cases, and those for nontuberculous affections in 95.23%. The mortality for the whole sample was of 2.23%. Nowadays, when empyemas generated by old methods of medico-surgical collapse and the chronic bacillary pleurisies are more and more seldom, the pulmonary decortication seems to improve its lesional results, and mainly to give better functional results.

Pulmonary function was evaluated in patients who were operated on for chronic empyema between October 1973 and October 1988. Fourteen patients underwent decortication, 61 were treated by the Kinchu method, 20 were treated by muscle flap and thoracoplasty, and one underwent pleuropnemonectomy. With decortication or the Kinchu method, significant postoperative improvement was noted in both percent forced vital capacity and FEV1/predicted initial capacity. However with muscle flap and thoracoplasty, percent forced vital capacity decreased. Ventilation and perfusion lung scan showed that pulmonary function improved in patients with good re-expansion of the lung who had suffered from short term lung collapse and no pathological changes in collapsed lung parenchyma.

The article discusses the efficacy of using polymeric hemostatic wool and plate in operations on the lungs and pleura in experiments. From the results of experimental studies the authors concluded that a biodegradable polyamide based on hexamethylenediamine and derivatives of amino acids in a model of parenchymatous-capillary bleeding from the lungs and pleura is an effective hemostatic. The authors recommend these polymers for use in the clinic.

Anatomo-surgical opportunities for a displacement of a lung to the operation side after pneumonectomy for the plasty of the remaining pleural cavity were studied in 17 corpses and 25 animal (dogs). The space between the sternum and mediastinum organs at the level of the II-IV ribs in human was shown to be of size enabling a lung lobe to be displaced to the opposite side as a wide "wedge". After pneumonectomy the cavity was partly filled with the pulmonary tissue and the bronchus stump of the removed lung was covered.