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When using an artificial pneumothorax (i.p.) there are often cases when it is the diseased part of the lung that cannot be compressed because of pleural adhesions, as a result of which the cavern continues to gape, the patient excretes sputum and bacilli, and continuation of i. i., in fact, is completely aimless. In rare cases, when the adhesions preventing the recession of the cavern are very thin, it is possible to rupture these adhesions by forceful blowing and bringing them to positive pressures. However, this method cannot be recommended for a number of reasons.

Qihua Gu,1,2 Xinhao Deng,1,2 Zhao Li,1,2 Jing Wang,3 Chengping Hu,1,2 Shuhua Lei,1,2 Xiaoling Cai1,2 1Department of Respiratory Medicine, Xiangya Hospital Affiliated to Central South University, Changsha, Hunan Province, 410008, People’s Republic of China; 2Key Cite of National Clinical Research Center for Respiratory Disease, Changsha, Hunan Province, 410008, People’s Republic of China; 3Department of Pathology, Xiangya Hospital Affiliated to Central South University, Changsha, Hunan Province, 410008, People’s Republic of ChinaCorrespondence: Qihua Gu Tel +86 15973196025Email guqh06@163.comBackground: Simple signs of local pleural adhesion are often found in people during a physical examination. In the present study, we aimed to clarify whether the merely localized pleural adhesion was just caused by previous pleural inflammation or physiological variation.Materials and Methods: Chest X-ray image materials were collected to analyze the incidence of simple pleural adhesions. Moreover, the causes of these simple pleural adhesions were further analyzed using thoracoscopy under direct vision and biopsy data.Results: In all 2218 chest X-ray images, 68 cases were found to have pleural lesions (3.07%), including 15 cases of localized pleural adhesion only. Subsequently, we analyzed the characteristics of 70 cases of pleural lesions using thoracoscopy. In two lung cancer patients with pleural metastasis, we found an unusual pleural junction. This connective strip was smooth and free of inflammation, resembling the normal pleura.Conclusion: Some of these purely localized pleural adhesions might be attributed to previous inflammation. However, there was still at least a possibility that there must be a physiological pleural junction, which could be the cause of the purely localized pleural adhesion shown in the chest radiograph.Keywords: pleural adhesion, bridge connection, physiological variation, image, thoracoscope

Pleural adhesions are a major challenge in standard and nonintubated video-assisted thoracic surgery. The currently available imaging techniques help to assess the presence and extent of pleural adhesions, but do not provide information on tissue deformability, which is crucial for intraoperative management. In this report, we describe the utilization of real- time elastography mapping of pleural adhesions. This technique enabled us to detect areas with softer adhesions, and helped establish the surgical plan in a difficult case of a patient scheduled for nonintubated video-assisted thoracic surgery.

Objective Pleural adhesion makes video-assisted thoracoscopic surgery (VATS) an arduous procedure and can increase postoperative pain from accompanying adhesiolysis. For the present study, the feasibility of lung ultrasonography for the prediction of pleural adhesions and postoperative pain in VATS was investigated. Design Blinded, prospective, observational study. Setting Tertiary teaching hospital, Seoul, South Korea. Participants Sixty patients (American Society of Anesthesiologists physical status I to III) scheduled to undergo VATS were assessed for eligibility. After exclusions, 53 patients were enrolled and followed-up. Interventions None. Measurements and Main Results Patients were evaluated with lung ultrasonography during deep spontaneous respiration before induction of anesthesia, and surgeons confirmed the presence of pleural adhesions during the surgery. Pain was evaluated using a numeric rating scale and by the amount of opioid consumption until 24 hours postoperatively. Lung ultrasonography showed acceptable predictability of pleural adhesions, with the area under the receiver operating characteristic curve (0.75, 95% confidence interval [CI] 0.67-0.83) and high specificity (0.97, 95% CI 0.91-0.99) but low sensitivity (0.53, 95% CI 0.38-0.68). The pain score was not different between sonographic adhesion (+) and (–) groups; however, the sonographic adhesion (+) group consumed more opioids until 24 hours postoperatively (fentanyl 675 [558-805] μg v 420 [356-476] μg; p Conclusions Lung ultrasonography may help with planning postoperative pain management in VATS; however, it was a better tool for ruling out rather than detecting pleural adhesions.

BackgroundThe presence of pleural adhesions may render video-assisted thoracoscopic surgery difficult or impossible. The aim of this study was to assess the value of chest ultrasonography in the detection of pleural adhesions prior to thoracotomy.MethodsBetween 2013 and 2014, 42 consecutive patients undergoing thoracotomies (including video-assisted thoracicsurgery) were evaluated with chest ultrasonography. These patients underwent a preoperative ultrasonic examination of the chestwall using a 7.5-10-MHz linear ultrasound probe at 7 points along the chest wall. We measured the movement of the visceral pleuralslide.ResultsIn the upper thoracic wall,ultrasonography demonstrated a sensitivity of 63.0%, a specificity of 66%, a negative predictive value of 77%, a positive predictive evalue of 50.0%, and an overall accuracy of 65.0%. And for the lower thoracic wall, ultrasonography demonstrated a sensitivity of 81.0%, a specificity of 59.0%,a negative predictive value of 89.0%, a positive predictivevalue of 44.0%, and an overall accuracy of 65.0%.ConclusionChest ultrasonography is moderately accurate in detecting the presence and location of pleural adhesions. The use of preoperative chest sonographic findings to plan trocar placement and to determine the need for an open approach is valuable in helping prevent visceral injury and facilitating video-assisted thoracoscopic surgery.

Background Video-assisted thoracoscopic surgery (VATS) has become the preferred approach for minimizing harm from thoracic operations. There is no report, however, which has discussed the feasibility of VATS in ipsilateral reoperation of major lung resection. Methods The present study included patients who had undergone ipsilateral reoperation of major lung resection by VATS from October 2009 to May 2017. Referring clinical data were recruited for analysis. Results Fourteen patients were recruited in the present study, including nine patients who underwent lobectomy and five who underwent segmentectomy during the second operation. Different hila were found in 6 patients, and pleural adhesions appeared in 10 patients. The average intraoperative blood loss was 203.6 ± 121.7 mL, and the mean operating room time was 2.2 ± 0.5 hours. There were no intraoperative deaths, and only one patient required conversion to thoracotomy. The average drainage time was 5.9 ± 4.6, and the mean hospital stay was 6.7 ± 4.2 days. Conclusion Though it is technically demanding to safely handle the changed hilum structure caused by the last operation, major lung resection by VATS is feasible for ipsilateral reoperation in appropriate candidates.

The application of VATS to perform multilevel tuberculous corpectomies and vertebral column reconstruction is an exciting frontier in the field of minimally invasive spine surgery. The approach avoids the morbidity of an open thoracotomy and several studies note its significant advantages. Despite the enthusiasm several additional studies note that pleural adhesions, the significant size of the granulomatous mass that must be removed, the inflamed nature of the involved tissues that predispose to bleeding, and infection itself, all of which characterize spinal tuberculosis, to be independent challenges associated with the technique. Despite these challenges the technique is described, and several centers report its success specifically in this context. Together with the technique itself most papers report, as part of any VATS series, a conversion rate from VATS to open thoracotomy of between 0 and 7%. In terms of why the need for conversion occurs, several papers divide the reasons into technical factors, the most important of which being poor visualization due to dense pleural adhesions, bleeding factors, and anatomical factors. How the conversion should be performed is also described, and distinguishing the specific technique in emergent conversions, compared to planned conversions, is a fundamental principle. We describe an adult male patient who presented to our unit acutely paraplegic secondary to T9-T11 tuberculous destruction with acute kyphotic angulation. While we initially took him to the operating room for an intended VATS multi-level corpectomy and vertebral column re-construction, unacceptable bleeding from the intercostal segmental vessels forced us to emergently convert to an open thoracotomy. This conversion enabled us to avoid an emergency, and an adverse patient outcome, and we report him being independently ambulant at his 6-month out-patient appointment. Our case highlights what should not be regarded as a failure, and we further provide a review of the literature on this specific topic.

Background Although preoperative detection of pleural adhesions is important in thoracic surgery, it is not widely performed. We report the availability of a pocket-sized ultrasound device for the preoperative detection of pleural adhesions. Methods Between September 2019 and September 2020, pleural adhesions were assessed preoperatively using a pocket-sized ultrasound device in 62 patients who underwent thoracic surgery. Evaluations were performed using the Vscan Dual Probe on the wards or just before surgery in the operating theater. We used a linear probe to scan the chest wall where the incision was scheduled, and evaluated the sliding sign. We compared ultrasound results with intraoperative findings. Results Of the 62 patients, the sliding sign was observed in 58 patients, 56 of whom demonstrated no pleural adhesions intraoperatively. The sensitivity was 96.6%. Four patients were negative for the sliding sign; of these, three had pleural adhesions and one did not. The specificity was 75.0%. Among all 62 patients, the diagnostic accuracy of ultrasound for pleural adhesions was 95.2%. False negatives were caused by loose adhesions. False positives were caused by the absence of vertical lines on ultrasound. Accuracy was not influenced by the timing of the test. Conclusions A pocket-sized ultrasound device was useful for the preoperative detection of pleural adhesions in thoracic surgery.

Breath-hold diving is a common practice as a part of military dive training. An association between prior lung injury and a propensity for lung barotrauma may have the potential to impact mission readiness for combat divers, Pararescue, Combat Controllers, Army Engineer divers, and various units in Naval Special Warfare and Special Operations. Barotrauma is a common complication of diving, typically occurring at depths greater than 30 m (98.4 ft). Individuals with abnormal lung anatomy or function may be at increased risk of barotrauma at shallower depths than those with healthy lungs, rendering these service members unfit for certain missions. We describe the case of a 25-year-old male, with a remote history of polytrauma and resultant pulmonary pleural adhesions, whose dive training was complicated by lung barotrauma at shallow depths. In missions or training utilizing breath-hold diving, the association with secondary alterations in lung or thoracic anatomy and function may limit which service members can safely participate.

Background: The purpose of our cohort study was to investigate the effects of pleural adhesions on perioperative outcomes in patients undergoing video-assisted thoracoscopic surgery (VATS) lobectomy for non-small-cell lung cancer (NSCLC). Methods: We performed a single-center retrospective analysis on the prospectively-maintained dataset at our unit from February 2014 to November 2015. Patients were divided into two groups (Group A: presence of pleural adhesions; Group B: absence of pleural adhesions) according to our grading system of pleural adhesions when entering the chest cavity. Demographic differences in perioperative outcomes between these two groups were initially estimated. A multivariate logistic-regression analysis was then performed to confirm the predictive value of the presence of pleural adhesions. Results: A total of 593 NSCLC patients undergoing VATS lobectomy were enrolled. The conversion and postoperative morbidity rates were 3.2% and 29.2%, respectively. There were 154 patients with pleural adhesions (Group A) and 439 patients without pleural adhesions (Group B). Group A patients had significantly higher rates of conversion to thoracotomy (9.1% vs . 1.1%; P vs . 14.4%; P=0.006) than those of Group B patients. No significant difference was found in the overall morbidity and cardiopulmonary complication rates between these two groups. The presence of pleural adhesions was also significantly associated with the prolonged length of chest tube drainage (logrank P Conclusions: Presence of pleural adhesions can predict conversion to thoracotomy and postoperative surgical complications in patients undergoing VATS lobectomy for NSCLC. Our study calls for an internationally accepted grading system for the presence of pleural adhesions to stratify the surgical risk.

Relevance Currently, the choice of effective and safe means for chemical pleurodesis is an urgent problem in the surgical treatment of spontaneous pneumothorax.Objective The purpose of our research was to compare the effectiveness of various methods of pleurodesis in the experiment based on the macro and microscopic study material.Materials and methods We used laboratory rats of the WISTAR line, weighing 180 grams, 200 individuals in the experiment. They were divided into three experimental groups and a control group of 50 rats each. Spontaneous pneumothorax was simulated on one side of the thorax of rats. One of the chemical agents was used in three experimental groups for carrying out the pleurodesis. The animals were observed and sacrificed in groups on days 3, 5, 7, 10, 30 of the experiment. Next, macro and microscopic changes in the lungs and adjacent tissues were described and compared. Regression models were constructed for the change in the number of free cell populations in the lung tissue during the process of analyzing data.Results and its discussion The use of a 6% solution of hydrogen peroxide causes the formation of persistent pleural adhesions with a shorter duration and severity of the inflammatory process in comparison to the analogues. Regression models of the dynamics of the free cellular composition of the pulmonary stroma were created with the aim of predicting the adhesion process.Conclusions The findings suggest that 6% solution of hydrogen peroxide have the maximum efficiency as a chemical agent for pleurodesis.

Background: Pneumothorax after bronchoscopic lung volume reduction using one-way endobronchial valves (EBVs) in patients with advanced emphysema occurs in approximately 20% of patients. It is not well known which factors predict the development of pneumothorax. Objective: To assess whether pleural adhesions on pretreatment high-resolution computed tomography (HRCT) scans are associated with pneumothorax occurrence after EBV treatment. Methods: HRCT scan analyses were performed on all patients who received EBV treatment in a randomized controlled trial. Three blinded readers scored adhesions by number and by measuring the longest axis of each pleural adhesion in the treated lung. The Pleural Adhesion Score (PAS) was calculated by adding 1 point for each small pleural lesion (5 mm). Results: The HRCT scans of 64 treated patients were assessed, of whom 14 developed pneumothorax. Patients who developed pneumothorax had a higher median number of pleural adhesions, 2.7 (IQR 1.9-4) compared to 1.7 (1-2.7) adhesions in the group without pneumothorax (p < 0.01). The PAS in the group with pneumothorax was higher compared to that in the group without: 14.3 (12.4-24.1) versus 6.7 (3.7-11.2) (p < 0.01). A threshold PAS of ≥12 was associated with a higher risk of pneumothorax (OR 13.0, 95% CI 3.1-54.9). A score Conclusion: A higher number of pleural adhesions on HRCT with a subsequent higher PAS in the treated lung is associated with a higher occurrence of pneumothorax after EBV treatment.

Endovascular aortic treatment is being performed more often and offers some advantages over open surgery. Nevertheless, open repair of thoracoabdominal aortic aneurysms is still relevant in complex cases, including combined chronic aortic dissection, congenital aortic abnormalities such as aberrant right subclavian artery, and dense pleural adhesions after a previous thoracotomy. We describe our successful use of open repair in a 46-year-old man who had these multiple abnormalities.

Background: Medical thoracoscopy (MT) is the gold-standard to investigate unexplained pleural exudates. However, the major prerequisite is an easy pleural access obtained by creating an artificial pneumothorax at the beginning of the procedure which can be a challenge in case of pleural adhesions and make the procedure unsafe. The detection of pleural adhesions prior to MT is necessary. Nowadays chest ultrasonography (CUS) is considered the best procedure to detect pleural adhesions. However, this technique is not available in all countries where the assessment of the pleural cavity is only based on chest radiography. Therefore, we conducted this study to compare the performance of lateral decubitus chest radiography (LDCR) and CUS to predict pleural adhesions. Methods: LDCR and CUS were performed prior MT in consecutive patients presenting exudative pleural effusion to detect pleural adhesions. The diagnostic sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy for each pre thoracoscopy procedure were calculated. Results: Data analysis for the sixty-six enrolled patients showed a higher superiority to detect pleural adhesions for CUS in comparison to LDCR for all the parameters analyzed. Conclusions: These results confirm that pre-MT CUS is the cornerstone to evaluate the access to the pleural cavity and justify educational program in this field in all centers which intends to develop interventional pulmonology.

Introduction: Prolonged air leak (PAL) is one of the main complications of the postoperative period in modern thoracic surgery. Although many studies have been set worldwide and a lot of possible risk factors have been examined, this issue remains controversial. Aims and Objectives: The aim of this study was to reveal the incidence, risk factors of PAL and to analyze its outcomes and safety of outpatient management. Methods: We retrospectively analyzed 319 consecutive patients submitted to lobectomy, bilobectomy, segmentectomy, and wedge resections from January 2012 till August 2015. PAL was defined as air leak lasting more than 7 days after surgery. Results: The incidence of a prolonged air leak was 14,7%. Bronchial obstruction (p Conclusions: Bronchial obstruction, low BMI, hypoproteinemia, lob- and bilobectomy, pleural adhesions, length of stapler line, use of suction drainage, the presence of subcutaneous emphysema and incomplete re-expansion of the lung were identified as risk factors of PAL. It had no influence on outcomes, except prolongation of hospital stay that can be effectively solved by discharge with Heimlich valve.

Background/aim Video-assisted thoracic surgery (VATS) for ipsilateral reoperations is challenging because of the potential for pleural adhesions. Insertion of the initial port can lead to lung injury because of the blinded intrathoracic area. We assessed the usefulness of ultrasonography before VATS to reduce the incidence of lung injury at the time of the initial port insertion during secondary ipsilateral VATS. Patients and methods Thirty-three patients who underwent repeat VATS for ipsilateral pulmonary lesions were included. All patients underwent preoperative ultrasonography to assess the possible presence of pleural adhesions using the lung sliding sign. Results Seven adhesions were found at the VATS ports. Two of these adhesions were not evaluated as pleural adhesions using ultrasonography; however, they were loose. All initial ports were inserted without lung injury. There were no major complications. Conclusion Preoperative detection of pleural adhesions using ultrasonography can determine the best initial port for secondary ipsilateral VATS.

portuguesDescreve-se os aspectos epidemiologicos, clinicos, patologicos e bacteriologicos da pleuropneumonia por Mannheimia haemolytica em caprinos, apos transporte prolongado. Quarenta caprinos transportados da regiao Nordeste para a regiao Sul do Brasil morreram durante a viagem ou 2-3 dias apos o desembarque. Clinicamente, observou-se dispneia, secrecao nasal mucopurulenta e tosse. Na necropsia foram coletados multiplos fragmentos de orgaos para analises histopatologicas e identificacao do agente envolvido. Todos os pulmoes apresentaram consolidacao pulmonar predominantemente em regiao cranioventral, associada a deposicao acentuada de fibrina, espessamento e aderencia pleurais em 90% dos casos. Histologicamente, havia pleuropneumonia fibrinossupurativa caracterizada por infiltrado neutrofilico difuso associado a fibrina. Colonias nao hemoliticas [85% (34/40)] e hemoliticas [15% (6/40)] foram obtidas pelo isolamento bacteriologico. Mannheimia spp. foi isolada em 26 amostras, os quais posteriormente foram confirmados como Mannheimia haemolytica (99% de identidade), pela amplificacao e sequenciamento parcial do gene 16S rDNA. O estresse pode favorecer o desenvolvimento de pleuropneumonia bacteriana em caprinos, e cepas nao hemoliticas de M. haemolytica podem causar doenca em animais com imunodepressao acentuada. Palavras-chave: doencas de caprinos; doencas respiratorias; patologia; PCR EnglishThis study described the epidemiological, clinical, pathological and bacteriological aspects of Mannheimia haemolytica pleuropneumonia in goats associated with shipping stress. Forty goats transported from the Northeast to the Southern region of Brazil died during shipment, or 2-3 days after unloading. Clinical signs included dyspnea, mucopurulent nasal discharge, and coughing. All goats were necropsied, and multiple tissues were collected for histopathological analysis and involved agent identifications. All lungs showed pulmonary consolidation, predominantly affecting the cranioventral lobes, in addition to the marked fibrinous pleuritis, pleural thickening, and pleural adhesions, that affected 90% of the goats. Histologically, there was fibrino-suppurative pleuropneumonia characterized by a diffuse neutrophilic infiltrate admixed with fibrin. Non-hemolytic [85% (34/40)] and hemolytic [15% (6/40)] species were obtained in bacteriological culture. Fir Mannheimia spp. was reported in 26 isolates and subsequently confirmed as M. haemolytica (99% identity), after amplification and partial sequencing of the 16S rDNA gene. Stress may trigger the development of bacterial pleuropneumonia in goats, and non-hemolytic strains of M. haemolytica may cause this condition in goats with severe immunosuppression. Key words: goat diseases; respiratory diseases; pathology; PCR

The purpose of this study was to evaluate Radio Frequency Ablation (RFA)-assisted lung parenchymal transection through thoracotomy and thoracoscopy. Twelve domestic pigs underwent RFA-assisted lingulectomy: six through thoracotomy (group A), and six with thoracoscopy (group B). There was no mortality, no bleeding, or air leak intra- or postoperatively in either of the groups, and no conversion to open thoracotomy in group B. Group A had longer operating period and more pleural adhesions. A barotrauma, a skin burn, and a localized infection were observed in this group. Histopathology confirmed a sharply demarcated area of coagulation necrosis without damage to adjacent structures. RFA-assisted lung resection through thoracotomy bears the inherent problems of an open approach, and the use of RFA device does not add to morbidity. The thoracoscopic use of RFA probe by experienced surgeons is considered safe, maintaining the advantages of key-hole surgery.

Objective At present, minimal invasive direct coronary artery grafting is the least invasive nonrobotic surgical approach to revascularize the left anterior descending artery with the left internal mammary artery. Total endoscopic coronary bypass grafting is performed with the help of a telemanipulator (“robot”). A prospective proof-of-concept study was initiated to investigate a nonrobotic total endoscopic coronary bypass grafting approach. Methods Twenty patients with significant left anterior descending artery or left main stem lesion were operated on via three or four left thoracic access ports. Under exclusive endoscopic vision, the left internal mammary artery was harvested and anastomosed to the left anterior descending artery manually. Cardiopulmonary bypass and cardioplegic arrest were planned in all cases. Results In 10 patients, the operation was completed successfully as nonrobotic total endoscopic coronary bypass grafting. Reasons for conversions to minimal invasive direct coronary artery grafting or conventional sternotomy were dense pleural adhesions (3 patients), bleeding of the anastomosis (3), diffuse bleeding during left internal mammary artery harvesting (2), identification problems of the target artery (1), or left internal mammary artery failure (1). Postoperative angiography in five primarily successful nonrobotic total endoscopic coronary bypass grafting patients showed patent anastomoses in four cases. One patient was reoperated on for early anastomotic failure in a 1.0-mm target vessel. Until now, a percutaneous coronary intervention of remaining lesions as staged hybrid procedure was performed in three patients (2 nonrobotic total endoscopic coronary bypass grafting, 1 minimal invasive direct coronary artery grafting). Conclusions With a thoroughly surveyed learning curve, nonrobotic total endoscopic coronary bypass grafting procedure could become an alternative to other available treatment options; however, the value of the procedure has to be further investigated.

Background: Until now, the traditional procedure to treat intralobar pulmonary sequestration (ILS) in adults has been a lobectomy performed by open chest surgery. We have reviewed our data to determine whether the surgical management of these lesions has evolved over the last years. Methods: We retrospectively reviewed the records of patients who were operated on for an ILS by either posterolateral thoracotomy (PLT group), or by thoracoscopy (TS group) between 2000 and 2016. Results: Eighteen patients were operated on for a ILS during this period. Before 2011, all resections were performed by thoracotomy (n=6) and after 2011 the approach was either a thoracotomy (n=5) or a thoracoscopy (n=7). There was one conversion because of dense pleural adhesions and this patient was integrated in the PLT group for further analysis. ILS presented more frequently on the left side (n=12, 66.7%) than on the right one (n=6, 33.3%) and exclusively in the lower lobes. All the PLT group patients underwent a lobectomy. In the TS group, five patients underwent a sublobar resection (2 segmentectomies S9+10, 1 basilar segmentectomy and 2 atypical resections). There was no mortality. In the PLT group, 5 patients (45%) had complications versus one patient (14%) in the TS group. The mean hospital stay was 7.4 days in the PLT group versus 5.4 days in the TS group. Conclusions: These data confirm that ILS can be safely treated by a sublobar resection that should be performed, whenever possible, without opening the chest.

Мета роботи – вивчити значення ультрасоноскопії у вчасному виявленні синдрому плеврального випоту з огляду на характер виявлених змін, рівень променевого навантаження та розвиток і поширеність плевральних нашарувань. Матеріали та методи – досліджено 329 хворих із СПВ, які були розподілені на дві групи. В основну групу увійшло 142 особи, базовим методом променевої діагностики у яких була традиційна рентгенографія; у групу порівняння – 187 хворих, базовим методом променевої діагностики при цьому була ультрасоноскопія, яка доповнювалася рентгенографією. Результати та обговорення. Після первинного променевого обстеження 134 (94,4 %) хворим основної групи був виставлений діагноз синдрому плеврального випоту і вони були направлені до спеціалізованої клініки для верифікації процесу. У групі ж порівняння плевральний випіт було виявлено лише у 10 (5,3 %) хворих. Жодних змін на рентгенограмах не знайдено у 52 (27,8 %) осіб. Вони отримували лікування за місцем проживання з приводу «неврологічних», «терапевтичних» та «хірургічних» захворювань. У інших 125 (66,9 %) хворих встановлено «пневмонію» і проводилось лікування за місцем проживання у дільничних чи районних лікарнях. Таким чином верифікація діагнозу затримувалася у середньому на 3-4 тижні. Поміж хворих основної групи при торакоскопії нашарування констатовано у 43 (30,3 %) осіб, і у 156 (83,4 %) хворих групи порівняння, що частіше у 2,8 разу. При цьому нашарування площею від 2 до 4 % у групі порівняння трапилися у 33,1 %, що частіше, ніж у основній групі у 2,9 разу. Нашарування поширеністю від 5 до 6 % площі тіла у групі порівняння мали місце у 58 (31,0 %) осіб, що частіше у 7,4 разу, ніж у основній групі. Нашарування понад 6 % у групі порівняння мали місце у 10,7 %, а у основній групі не трапилися зовсім. Висновки. Використання ультрасоноскопії у комбінації з рентгенографією органів грудної порожнини дозволяє виявити плевральний випіт у 94,4 % хворих з підозрою на СПВ та пришвидшити діагностику захворювання на 3–4 тижні. За рахунок раннього виявлення плеврального випоту методом ультрасоноскопії та рентгенографії органів грудної порожнини з подальшою торакоскопією плевральні нашарування визначаються у 2,8 разу рідше в порівнянні з хворими, обстеженими лише рентгенологічно. У хворих основної групи нашарування площею 2–4 % площі тіла мають місце у 11,3 % хворих проти 33,1 % хворих групи порівняння; площею 5–6 % – у 4,2 % та 31,0 % відповідно. Ураження плеври площею понад 6 % у хворих основної групи не розвиваються, у хворих групи порівняння мають місце у 10,7 %. Цель работы – изучить значение ультрасоноскопии в своевременном выявлении синдрома плеврального выпота, учитывая характер выявленных изменений, уровень лучевой нагрузки и развитие и распространенность плевральных наслоений. Материалы и методы. Исследованы 329 больных с синдромом плеврального выпота, которые были разделены на две группы. В основную группу вошло 142 человека, базовым методом лучевой диагностики которых была традиционная рентгенография; в группу сравнения – 187 больных, базовым методом лучевой диагностики при этом была ультрасоноскопия, которая дополнялась рентгенографией. Результаты и обсуждение. После первичного лучевого обследования 134 (94,4 %) больным основной группы был установлен диагноз синдрома плеврального выпота и они были направлены в специализированную клинику для верификации процесса. В группе же сравнения плевральный выпот был обнаружен только у 10 (5,3 %) больных. Никаких изменений на рентгенограммах не найдено у 52 (27,8 %) человек. Они получали лечение по месту жительства по поводу «неврологических», «терапевтических» и «хирургических» заболеваний. Остальным 125 (66,9 %) больным установлена «пневмония», лечение которой проводилось по месту жительства в участковых или районных больницах. Таким образом, верификация диагноза задерживалась в среднем на 3-4 недели. Среди больных основной группы при торакоскопии наслоения констатированы у 43 (30,3 %) человек, и у 156 (83,4 %) больных группы сравнения, что чаще в 2,8 раза. При этом наслоения площадью от 2 до 4 % в группе сравнения зафиксированы в 33,1 % случаев, что чаще, чем в основной группе в 2,9 раза. Наслоения распространенностью от 5 до 6 % площади тела в группе сравнения имели место у 58 (31,0 %) человек, что чаще в 7,4 раза, чем в основной группе. Наслоения более 6 % в группе сравнения имели место у 10,7 % случаев, а в основной группе не встречались вовсе. Выводы. Использование ультрасоноскопии в сочетании с рентгенографией органов грудной полости позволяет выявить плевральный выпот у 94,4 % больных с подозрением на СПВ и ускорить диагностику заболевания на 3-4 недели. За счет раннего выявления плеврального выпота методом ультрасоноскопии и рентгенографии органов грудной полости с последующей торакоскопией плевральные наслоения определяются в 2,8 раза реже по сравнению с больными, обследованными только рентгенологически. У больных основной группы наслоения площадью 2-4 % площади тела имеют место у 11,3 % больных против 33,1 % больных группы сравнения; площадью 5-6 % – у 4,2 % и 31,0 % соответственно. Поражение плевры площадью более 6 % у больных основной группы не развиваются, в группе сравнения имеют место у 10,7%. Materials and methods – 329 patients with syndrome of pleural effusion were studied, which were divided into two groups. The main group included 142 people, the basic method of radiological diagnosis in which was the traditional X-ray; in the comparison group – 187 patients, the basic method of radiological diagnosis was ultrasonoscopy, which was supplemented by X-ray. Results and discussion. After initial radiological examination of 134 (94,4 %) patients of the main group were diagnosed syndrome of pleural effusion and they were sent to a specialized clinic for the verification of the process. In the same comparison group, pleural effusion was detected in only 10 (5,3 %) patients. No changes in radiographs were found in 52 (27,8 %) persons. They received treatment at the place of residence for «neurological», «therapeutic» and «surgical» diseases. In other 125 (66,9 %) patients, there was «pneumonia» and treatment was performed at the place of residence in district or regional hospitals. Thus, the verification of the diagnosis was delayed by an average of 3-4 weeks. Among patients of the main group, at thoracoscopy pleural adhesions were recorded in 43 (30,3 %) persons, and in 156 (83,4 %) patients in the comparison group, which was more often 2,8 times. In this case, layering with an area of 2 to 4 % in the comparison group occurred in 33,1 %, which is more frequent than in the main group 2,9 times. Pleural adhesions of prevalence from 5 to 6 % of the body surface area in comparison group occurred in 58 (31,0 %) persons, which is more often 7,4 times than in the main group. Pleural adhesions more than 6 % in the comparison group took place in 10,7%, and in the main group did not happen at all. Conclusions. The use of ultrasonoscopy in combination with radiography of the chest organs allows to detect pleural effusion in 94,4 % of patients with suspected syndrome of pleural effusion and to accelerate the diagnosis of the disease for 3-4 weeks. Due to the early detection of pleural effusion by ultrasonoscopy and radiography of the chest cavity with subsequent thoracoscopy, the pleural adhesions are determined 2,8 times less frequently compared with patients, examined only radiologically. In patients of main group pleural adhesions of 2-4 % of the body area occur in 11,3 % of patients versus 33,1 % of patients in the comparison group; in the area of 5-6 % – in 4,2 % and 31,0 % respectively. Defeat of the pleura in the area of more than 6 % of patients in the main group does not develop, in patients with a comparison group occur in 10,7 %.

Based on experience gained at the Hyperhidrosis Outpatient Clinic of the Hospital of Clinicas of Sao Paulo, Brazil, with videothoracoscopic thoracic sympathectomy, in this chapter the evolution of the surgical method—including anesthesia, the patient’s position on the surgical table, and the target segment of the sympathetic chain, as well as the contraindications and difficulties encountered in performing the surgical procedure, particularly in the presence of the azygous lobe—are described.

This chapter discusses the most common technical difficulties during the surgical procedure of sympathectomy, as well as the most frequent surgical complications, based on the literature and experience of the group with more than 2000 operated cases. The most frequent and most compromising technical difficulty is the presence of pleural adhesions. The most frequent immediate complication is the air fistula, and the most frequent late complication is compensatory sweating.

Background Video-assisted thoracic surgery (VATS) plays an important role in thoracic surgery because it is less invasive. However, the existence of severe pleural adhesions may make VATS difficult and complicated. The aim of this study was to assess the utility of inspiration and expiration computed tomography (respiratory dynamic CT (RD-CT)) in evaluation of pleural adhesions preoperatively. Methods RD-CT was performed on 107 patients undergoing thoracotomies (both VATS and open). We assessed synchronous motion during respiration on RD-CT. Comparing the results of RD-CT and intraoperative findings, we assessed the utility of preoperative evaluation. Results A negative correlation between sliding score and adhesion grade was revealed. Sliding score in adhesion negative patients was significantly higher than that in adhesion positive patients (P

The time required for the effective clearance of pleural adhesions/organization after intrapleural fibrinolytic therapy (IPFT) is unknown. Chest ultrasonography and computed tomography (CT) were used to assess the efficacy of IPFT in a rabbit model of tetracycline-induced pleural injury, treated with single-chain (sc) urokinase plasminogen activators (scuPAs) or tissue PAs (sctPA). IPFT with sctPA (0.145 mg/kg; n = 10) and scuPA (0.5 mg/kg; n = 12) was monitored by serial ultrasonography alone ( n = 12) or alongside CT scanning ( n = 10). IPFT efficacy was assessed with gross lung injury scores (GLIS) and ultrasonography scores (USS). Pleural fluids withdrawn at 0–240 min and 24 h after IPFT were assayed for PA and fibrinolytic activities, α-macroglobulin/fibrinolysin complexes, and active PA inhibitor 1 (PAI-1). scuPA and sctPA generated comparable steady-state fibrinolytic activities by 20 min. PA activity in the scuPA group decreased slower than the sctPA group ( kobs = 0.016 and 0.042 min−1). Significant amounts of bioactive uPA/α-macroglobulin (but not tPA; P < 0.05) complexes accumulated at 0–40 min after IPFT. Despite the differences in intrapleural processing, IPFT with either fibrinolysin was effective (GLIS ≤ 10) in animals imaged with ultrasonography only. USS correlated well with postmortem GLIS ( r2 = 0.85) and confirmed relatively slow intrapleural fibrinolysis after IPFT, which coincided with effective clearance of adhesions/organization at 4–8 h. CT scanning was associated with less effective (GLIS > 10) IPFT and higher levels of active PAI-1 at 24 h following therapy. We concluded that intrapleural fibrinolysis in tetracycline-induced pleural injury in rabbits is relatively slow (4–8 h). In CT-scanned animals, elevated PAI-1 activity (possibly radiation induced) reduced the efficacy of IPFT, buttressing the major impact of active PAI-1 on IPFT outcomes.

Mycoplasma pneumonia is common agent causing community acquired pneumonia in younger population. However, the course of illness is usually benign and is rarely associated with pulmonary complications. We report a 27 years old female patient with unilateral pneumonia followed by pleural effusion and adhesions on the same side. This potential source of infection should be considered in young patients where resolution of symptoms from pneumonia is delayed. Keywords : Mycoplasma pneumoniae , community acquired pneumonia, pleural effusion, pleural adhesions

Objective: Single-incision thoracoscopic surgery (SITS) is being applied to various thoracic diseases because it produces a smaller surgical scar, and is associated with less pain and loss of sensation compared to the traditional 3-port video-assisted thoracoscopic surgery (VATS). In our previous study, we showed that SITS can be used as a first-line surgical method to treat primary spontaneous pneumothorax. Therefore in this study, we looked into whether SITS can be safely and conveniently applied to other various thoracic diseases. Methods: The subjects for this study those patients who underwent SITS at this hospital for thoracic diseases, who were admitted to this hospital between December 2013 and February 2015. Results: In this study, SITS was attempted in 50 patients with various thoracic diseases. In 46 cases, SITS was successfully performed. However, in the remaining 4 cases were converted to 2-port or 3-port VATS (8%, 4/50). The reasons for conversion to VATS was due to difficulty in approaching the lesion (n = 3) and severe pleural adhesion (n = 1). Conclusion: We found that SITS is a relatively easy and safe procedure that can be applied to various thoracic diseases. However, the operation may be difficult to perform depending on the location of the lesions or the extent of pleural adhesions. Therefore we recommend SITS in conditions where the lesion is mainly in the upper lobe, such as spontaneous pneumothorax, and in patients with minimal level of pleural adhesions.

A range of incisional techniques are available to lung transplant surgeons. Since the early 1990s, the standard for those undertaking bilateral lung transplant surgeries, particularly for septic disease, has been the clamshell incision or its anterior thoracotomy variants. There are potential problems of either incisional instability or reduced access. A relatively unused alternative that is very familiar to all cardiac and many thoracic surgeons is median sternotomy. Although pleural adhesions can cause a spectrum of difficulties, in their absence, the advantages of rapid opening and closure, combined with reliable stability and minimal discomfort, make this an attractive option. A series of evolved surgical maneuvers, with an emphasis of what can be done intrapericardially, facilitates this approach, and we describe them in this article.

Background Over 50 000 patients with malignant pleural effusion (MPE) are seen annually in the UK. The majority develop recurrent symptomatic disease requiring definitive treatment. MPE is most frequently managed with talc slurry pleurodesis via intercostal chest drain. This involves a lengthy inpatient stay and has a success rate of around 70%, with no means of predicting which patients will suffer pleurodesis failure. Thoracic ultrasound (TUS) is widely used by respiratory physicians, and data from animal and human studies suggest it can identify pleural adhesions (through the absence of normal lung sliding) in a range of conditions. By extension, TUS may allow clinicians to diagnose the presence or absence of adhesions post-pleurodesis in MPE, identifying patients suitable for discharge or needing further intervention. Method We recruited 18 adult patients with MPE undergoing drainage and talc slurry pleurodesis to a prospective single-centre cohort study. Patients underwent standardised TUS assessment pre- and post-pleurodesis, evaluating pleural sliding and adhesions at nine points (three anterior, three lateral, three posterior) across the affected hemithorax. Lung sliding was graded as per Zhu et al.,1 creating a total pleurodesis score out of 18. Pleurodesis failure was defined as radiological and symptomatic fluid recurrence in the same hemithorax requiring further intervention at any point up to 3 months post-pleurodesis. Patients also completed a questionnaire addressing satisfaction with TUS assessment. Results 3/18 patients (16.7%) died before 1 month follow-up. Of 15 patients seen at one month, 11 (73.3%) had successful pleurodesis and 4 (26.7%) had failed. No patient had delayed pleurodesis failure between 1 and 3 month follow-up. There was a significant difference observed in the day 1 TUS pleurodesis score between patients who went on to have successful pleurodesis and those who failed during follow-up (table 1). TUS assessment was acceptable to patients, with none considering it either time-consuming or unwilling to have it again if needed. Conclusion Our data suggest TUS assessment 24 hours post-pleurodesis for MPE predicts success or failure of this intervention, with significant implications for clinical care. A larger randomised study is now underway to further evaluate this hypothesis. Reference Chest2005;128(2):934–9.

OBJECTIVES To assess lung respiratory movement ("lung sliding") in dogs using B-mode ultrasonography (US) and to develop a method that assesses adhesions between the parietal pleura and the lung. METHODS Seventeen male beagles were anesthetized, and respiratory management was performed with intermittent positive pressure ventilation. Lung-sliding assessments and adhesion examinations were performed with lung US under general anesthesia before and 2 weeks after thoracotomy. Lung sliding was scored on a 4-level scale based on the percentage of the area that showed lung sliding (3, an area of roughly ≥80% of the intercostal space; 2, about 50% of the area of the intercostal space; 1, a small area of the intercostal space; or 0, movement absent); scores of 0, 1, and 2 indicated adhesions, whereas a score of 3 indicated no adhesions. The animals were then euthanized, and necropsy was performed to examine pleural adhesions. RESULTS Lung US and necropsy findings were compared. The median lung-sliding score for the 12 sites with pleural adhesions on necropsy was 1.5, whereas it was 3.0 for the 532 sites without pleural adhesions. The lung-sliding score was significantly lower in the group with adhesions (P

We describe a new video-assisted technique for the management of a giant midesophageal diverticulum using a single 5-cm port. It maintained the same principles of the traditional open technique as diverticulectomy, myotomy, and fundoplication. The better visualization of the main esophageal body, diverticulum, and esophagogastric junction and the better alignment of the stapler cartridge to the longitudinal axis of the esophagus are all technical factors supporting our procedure. Heavily calcified mediastinal lymph nodes and diffuse pleural adhesions are the main contraindications. However, future experiences are needed before this technique can be recommended as acceptable treatment. (C) 2017 by The Society of Thoracic Surgeons.

Purpose Tube thoracostomy is a common and generally safe procedure. However, potential hazards can occur during placement of the chest tube. Inasmuch as unexpected injuries may arise from tube thoracostomy, we propose a novel video-guided method. Description We used an independent complementary metal oxide semiconductor image sensor with a processing chip to obtain a front view image of the chest cavity. The device is connected to an aluminum shaft with four small light-emitting diode crystals in the tip, and a detachable small monitor with a battery inside. The apparatus is small and can be used to direct vision-guided tools in tube thoracostomy. Evaluation We performed video-guided tube thoracostomy in 6 patients with pleural adhesions. All patients experienced good tolerance to the procedure and had no immediate adverse events. The thoracostomies were performed by a single surgeon with good acceptability, and each procedure was completed in less than 10 minutes. Conclusions In some cases of pleural adhesion, the video-guided thoracostomy may be a safer alternative to non–image guided tube thoracostomy.

The investigation of care in the bioarchaeological record has focused on two broad circumstances: (1) long-term survival with disability in which functional independence is impossible and (2) healed/healing trauma or illness that would have necessitated intervention or care to ensure recovery and survival. These conditions reflect relatively extreme, life-or-death circumstances and thus provide the clearest opportunity to observe care. The preservation of soft tissue, however, not only affords the opportunity to observe a wider range of pathological conditions but presumably a greater chance of observing, or inferring, evidence of care. The first part of this chapter is a synthesis of the degree to which researchers have engaged (explicitly or otherwise) with the concept of care in the analysis of mummified remains. The second component of the chapter will focus on the case of an eighteenth to nineteenth century mummy from the Piraino Mother Church, in the province of Messina, Sicily. This individual exhibits evidence of pleural adhesions, whipworm infection, and skeletal evidence of multiple myeloma. Some level of care may be inferred based our understanding of the progression of this cancer. Care is more directly supported based on results of palynological analyses through which plants with known medicinal properties were identified.

Introduction: One of the most common indications for reoperation of pectus excavatum is bar displacement.1–5 The authors present a video of thoracoscopic redo of a Nuss procedure in a 16-year-old patient with a recurrence of pectus excavatum. She underwent a Nuss procedure 2 years before. She presented chronic pain and complaints of unsatisfactory cosmesis due to bar displacement. A redo of Nuss procedure was proposed. Materials and Methods: Surgery started with bar removal from its position in the fifth intercostal space. A bilateral thoracoscopy was performed with three ports (5 mm) on each side using previous scars. Multiple adhesions were identified between the visceral and parietal pleura along the pathway of the bar. Lysis of pleural adhesions was performed using electrocautery and/or blunt dissection with Endo Peanut. The new bar was inserted in the sixth intercostal space. The postoperative period was uneventful. Chest tube was removed at postoperative day 5. With 1 year of follow-up, the...

Background Spontaneous pneumothorax is a major and frequently recurrent complication of lymphangioleiomyomatosis (LAM). Despite the customary use of pleurodesis to manage pnenumothorax, the recurrence rate remains high, and accompanying pleural adhesions cause serious bleeding during subsequent lung transplantation. Therefore, we have developed a technique of total pleural covering (TPC) for LAM to wrap the entire visceral pleura with sheets of oxidized regenerated cellulose (ORC) mesh, thereby reinforcing the affected visceral pleura and preventing recurrence. Methods Since January 2003, TPC has been applied during video-assisted thoracoscopic surgery for the treatment of LAM. The medical records of LAM patients who had TPC since that time and until August 2014 are reviewed. Results TPC was performed in 43 LAM patients (54 hemithoraces), 11 of whom required TPC bilaterally. Pneumothorax recurred in 14 hemithoraces (25.9%) from 11 patients (25.6%) after TPC. Kaplan-Meier estimates of recurrence-free hemithorax were 80.8% at 2.5 years, 71.7% at 5 years, 71.7% at 7.5 years, and 61.4% at 9 years. The recurrence-free probability was significantly better when 10 or more sheets of ORC mesh were utilized for TPC (P = 0.0018). TPC significantly reduced the frequency of pneumothorax: 0.544 ± 0.606 episode/month (mean ± SD) before TPC vs. 0.008 ± 0.019 after TPC (P

Background Video-assisted thoracoscopic surgery (VATS) pulmonary lobectomy has been associated with decreased complication rates and length of stay compared with lobectomy by thoracotomy. No studies have addressed VATS lobectomy in Veterans Administration (VA) patients. Methods A retrospective review was undertaken of 50 VATS lobectomies performed between August 2007 and June 2009 by one surgeon in a VA hospital, a university-affiliated county hospital, and a private community hospital. Results VA patients had more medical comorbidities, poorer lung function, greater current smoker status, and fewer preoperative biopsies. Pleural adhesions or hilar lymphadenopathy were encountered more commonly in VA than nonfederal patients. Surgical times and number of procedures performed were greater in VA patients. There was no statistically significant difference in the risk of postoperative complications or chest tube duration although length of stay was longer for VA patients. Conclusions VATS lobectomy is feasible in a VA setting. The evidence strongly suggests that veterans can benefit from VATS lobectomy in terms of improved outcomes and diminished length of stay compared with thoracotomy.

Background Detecting pleural adhesions during the preoperative evaluation could greatly aid the surgeon in locating a safe entry site for trocar placement during thoracoscopy. However, there is currently no valid method for this. Objective The aim of the current study was to assess the accuracy of transthoracic ultrasound (TTU) in predicting intrathoracic adhesions prior to thoracic surgery. Material and Method We carried out a diagnostic test study of 117 patients undergoing VATS/thoracotomy. Attempts were made to identify pleural adhesions using TTU by one radiologist. The sites were categorized as “no adhesions” or “adhesions” that with respiration. During operation, adhesions in the area were graded by one surgeon blinded to the original prediction. Results Pleural slide test using TTU had a sensitivity of 88.0 %, a specificity of 82.6 %, and an overall accuracy of 83.8 %. Kappa analysis yielded a significant degree of agreement between the radiologist's predictions and the intraoperative findings with regard to the identification of trocar sites free of pleural adhesions compared to sites with pleural adhesions (p Conclusion TTU can accurately identify intrathoracic adhesions prior to thoracic operation.

Objective The aim of this study was to discuss the diagnosis and determine the optimal thoracoscopic surgical treatment of mediastinal bronchogenic cysts. Methods From May 1996 to April 2008, 13 consecutive patients with mediastinal bronchogenic cysts underwent thoracoscopic surgery at our institution. There were eight men and five women aged 16-74 years (mean age, 41.5 years). Results In the majority of patients (69.2%), there were no clinical symptoms and the lesions were found incidentally by chest radiography that was performed as part of physical screening. Lesions were found in the posterior mediastinum in five patients (38.5%) and in the upper mediastinum in four (30.8%). In the histopathological examinations, ciliary epithelium was observed in 13 patients (100.0%), bronchial cartilage in 7 patients (53.8%), bronchial glands in 6 patients (46.2%), and smooth muscle in 5 patients (38.5%). No serious postoperative complications were observed. In 3 patients (23.1%), conversion to open thoracotomy was necessary due to major pleural adhesions and intraoperative vascular injury. Conclusion Thoracoscopic resection of mediastinal bronchogenic cyst is minimally invasive and has no serious postoperative complications, and should therefore be considered as the primary therapeutic option.

Background and Aim of the Study Interest in sutureless aortic bioprostheses is growing because of the potential advantages that such devices can bring in facilitating minimally invasive approaches. Video assistance can potentially enhance details of decalcification and sutureless valve sizing. We review the feasibility of sutureless aortic valve replacement (AVR) via a minimally invasive video-assisted (MIVA) right anterior minithoracotomy. Methods Between November 2012 and November 2013, 21 patients were selected to undergo an AVR using the Enable sutureless device (Medtronic, Minneapolis, MN, USA) via a video-assisted right second space minithoracotomy. Results Procedural success of the MIVA approach was 95.3% (one conversion to median sternotomy due to severe pleural adhesions). Average aortic clamp time was 72.1 ± 22.1 min. No paravalvular leakage was detected at discharge. Thirty-day mortality was 4.7% (one patient, pulmonary embolism). Conclusions The described approach appears to be safe and feasible with adequate clamp times. Video assistance allows optimal visualization of the aortic root and accurate valve delivery, without conflict between the device, the camera, and the instruments, making this setting an encouraging baseline towards the assessment of the totally endoscopic approach. doi: 10.1111/jocs.12368 (J Card Surg 2014;29:494–496)