Search Results (47)

Introduction: Computed tomography-guided biopsies (CTGB) are essential in diagnosing various conditions, particularly in respiratory medicine, with lung cancer being a primary focus. A significant complication associated with CTGB is pneumothorax, which can occur in up to 26% of cases. At Northumbria Healthcare NHS Foundation Trust, a large interventional service collaborates closely with radiologists and respiratory physicians. This study aims to evaluate the incidence of pneumothorax following CTGB. Methods: A retrospective service review was conducted on all lung parenchymal CTGBs performed between April 2011 and July 2023, with approval from the local information governance. Demographic data and clinical outcomes were analyzed using descriptive statistics. Continuous variables are presented as medians with interquartile ranges (IQR), while categorical variables are reported as frequencies and percentages. Results: A total of 1492 CT-guided lung biopsies were analyzed. The median age of patients was 72 years (IQR 10.5), and 50.9% were male. Pneumothorax occurred in 23.8% (n = 355) of cases. Of these, 159 (44.8%) were detected on post-biopsy CT scans. The average number of pleural passes was 1.8 (range 1–4). Among those with pneumothorax, 53.6% had radiologically evident emphysema. The median forced expiratory volume in 1 s (FEV1) was 1.97 L (IQR 1.04). Sixty-seven percent (n = 234) of patients had no pleural contact, and the median lesion size was 26 mm (IQR 24). Seventy-two percent (n = 255) of lesions with pneumothoraces were less than 3 cm deep. Forty-four percent of biopsies were performed using 18 French gauge tru-cut needles. Of the 355 pneumothoraces, 89% (n = 315) were managed conservatively, with 42 requiring pleural intervention (41 small-bore 12 Fr intercostal chest drains and one pleural vent). Symptoms were initially present in 40 cases, and two cases developed symptoms up to 7 days post-procedure. Conclusions: The incidence of pneumothorax is consistent with expected rates, with more occurrences observed in biopsies of smaller lesions lacking pleural contact, lesions with surrounding emphysema, and cases requiring multiple pleural passes. FEV1 does not appear to influence the risk of pneumothorax. Conservative management is generally effective, without significant complications. Full article

Pneumothoraces are a common and potentially severe condition in the emergency setting. Various pathophysiological mechanisms (spontaneous and traumatic) could be involved, consequently defining the diagnostic–therapeutic pathway. Understanding these underlying etiologies is essential for advancing diagnostic strategies and guiding therapeutic measures. Recent insights into diagnostic and therapeutic strategies focus on the role of ultrasound and the effectiveness of small-bore chest tubes in managing all types of pneumothoraces with a reduced risk of complications. Moreover, observation is emerging as a possible conservative approach in hemodynamically stable patients regardless of the etiology of the pneumothorax. This review aims to provide a valuable resource to improve diagnostic and therapeutic management, comparing traditional methods and promising, less invasive therapeutic interventions. Full article

Background/Objectives: Microvascular plug embolization in the distal feeding artery (FA-MVP) and coil embolization targeting the nidus and feeding artery (NiFA-coil) are effective treatments for pulmonary arteriovenous malformations (PAVMs). This study compares their outcomes. Methods: A retrospective chart review was conducted on patients who underwent NiFA-coil or FA-MVP embolization for PAVMs between October 2014 and May 2024, with initial (short-term) follow-up chest CT imaging performed within 18 months, and the latest (long-term) follow-up performed at least 3 years post-treatment. Durable occlusion was defined as ≥70% shrinkage of the nidus or draining vein on follow-up CT. A Cox proportional hazards regression model assessed the association between technique and durable occlusion, with inverse propensity score weighting used to adjust for patient and PAVM characteristics. Results: A total of 142 PAVMs (48 FA-MVP, 94 NiFA-coil) in 85 patients were analyzed. Durable occlusion was 97.2% (138/142) at a median short-term follow-up of 4.2 months and 90.2% (37/41) at a median long-term follow-up of 56.0 months. Simple PAVMs were more frequent in the FA-MVP group (93.8%, 45/48) than in the NiFA-coil group (61.2%, 58/94) (p < 0.001). The NiFA-coil group had larger feeding arteries (3.8 mm vs. 2.3 mm, p < 0.001) and sac sizes (13.1 mm vs. 7.7 mm, p = 0.040). Short and long-term durable occlusion rates were comparable (NiFA-coil: 96.8% and 88.9%; FA-MVP: 97.8% and 92.9%, respectively; p > 0.99, p > 0.99). After propensity score matching, compared to FA-MVP, NiFA-coil had a hazard ratio for short-term persistence of 1.06 (95% CI, 0.16–6.99; p = 0.956). Conclusions: Both NiFA-coil and FA-MVP embolization are highly effective for PAVM treatment, with similar success rates. Full article

Background: Postoperative physiotherapy is a cornerstone of Enhanced Recovery After Surgery (ERAS) programs, especially following lung resection. Despite its importance, the literature lacks clear recommendations and guidelines, particularly regarding the role of incentive spirometry (IS). This study aims to determine whether incentive spirometry offers additional benefits over early ambulation alone in patients undergoing lung resection for primary lung cancer. Methods: We conducted a retrospective case–control study at the European Institute of Oncology (IEO) involving patients who underwent lung resection from June 2020 to June 2022. Patients were divided into two cohorts: early ambulation alone (control group) and early ambulation with IS (IS group). The primary endpoint was the rate of postoperative pulmonary complications. Secondary endpoints included length of hospital stay and time to chest drain removal. A propensity score-matched analysis was performed based on age, sex, and BMI. Data were compared using Chi-squared and Student’s t-tests as appropriate. Results: A total of 304 patients were included, with 153 in the intervention group and 151 in the control group. After propensity-score matching, 52 patients from each cohort were compared. No significant differences were found between the groups regarding postoperative oxygen requirement, fever, atelectasis, residual pleural space, need for bronchoscopy toilette, and re-hospitalization rate. IS group showed trends toward shorter hospital stays and lower time to chest drain removal, though without reaching statistical significance. Conclusions: IS did not significantly improve postoperative outcomes compared to early ambulation alone in patients undergoing lung resection for primary lung cancer. More extensive, prospective, randomized trials are needed to confirm these findings. Full article

Background: Significant intraoperative and postoperative blood loss are rare but possibly life-threatening complications after lung resection surgery either during open or minimally invasive procedures. Microporous Polysaccharide Haemospheres (ARISTA™AH) have demonstrated time-efficient haemostasis, lower postoperative blood volumes and a lower blood transfusion requirement, without any identified adverse events across other specialities. The primary aim of our study was to evaluate the impact of ARISTA™AH on short-term postoperative outcomes in thoracic surgery. Our secondary aim was to compare ARISTA™AH with other commonly used haemostatic agents. Methods: We retrospectively reviewed a prospectively collected database of consecutive early-stage lung cancer patients surgically treated in two European centres (October 2020–December 2022). Exclusion criteria included open surgery, patients with coagulopathy/anticoagulant medication, major intraoperative bleeding, non-anatomical lung resection and age <18 years. The cohort was divided into five groups according to the haemostatic agent that was used. Propensity score matching was used to estimate the effect of ARISTA™AH on various intra- and postoperative parameters (continuous and binary outcome modelling). Results: A total of 482 patients (M/F:223/259; VATS 97/RATS 385) with a mean age of 68.9 (±10.6) years were analysed. In 253 cases, ARISTA™AH was intraoperatively used to control bleeding. This cohort of patients had a significant reduction in total drain volume by 135 mls (standard error 53.9; p = 0.012). The use of ARISTA™AH did reduce the average length of a hospital stay (−1.47 days) and the duration of chest drainage (−0.596 days), albeit not significantly. In the ARISTA™AH group, we observed no postoperative bleeding, no blood transfusion requirement, no 30-day mortality and no requirement for redo surgery. The use of ARISTA™AH significantly reduced the odds of postoperative complications, as well as the need for transfusion and redo surgery. Conclusions: Our data showed that Microporous Polysaccharide Haemospheres are a safe and effective haemostatic device. Their use has a positive effect on the short-term postoperative outcomes of patients surgically treated for early-stage lung cancer. Full article

Background: Although general thoracic surgery is usually focused on adult patients, there are some settings of pediatric diseases which can benefit from thoracic surgical procedures. In this study, we retrospectively reviewed the contribution of general thoracic surgeons to pediatric patients in a high-volume hospital. Methods: From September 2002 to August 2024, 8897 consecutive patients were operated on; among them, 202 patients (2.2%) were younger than 18. Age, sex, operatory setting, side, indications, procedures, procedure duration, and perioperative mortality were collected for each patient. Results: Among the 202 patients younger than 18, 27 (13.3%) were 0–6 yo; 13 (6.4%) were 6–12 yo; 162 (80.1%) were 12–18 yo. In the first group, metapneumonic pleural effusion was the most frequent indication (44.4%) and chest drain the most frequent procedure (51.8%). No perioperative mortality was reported. In the second group, metapneumonic pleural effusion was the most frequent indication (30.7%) and chest drain the most frequent procedure (46.1%). No perioperative mortality was reported. In the third group, pneumothorax was the most frequent indication (41.3%) and bullectomy the most frequent procedure; (41.3%); one intraoperative death (0.4%) was reported in a case of major trauma. Conclusions: A general thoracic surgeon can effectively contribute to the surgical care of pediatric patients; in younger patients (<12 yo) urgent procedures related to infections are the most commonly performed; on the other hand, in patients aged between 12 and 18, elective procedures are more commonly performed, these being sympathectomy for hyperhidrosis and bullectomy for pneumothorax the most frequent. Full article

The management of malignant pleural effusions (MPEs) has developed hugely since the publication of the management of an MPE: British Thoracic Society (BTS) Pleural Disease Guideline 2010. The presence of an MPE reflects advanced or metastatic disease (excluding malignant pleural mesothelioma) and thus the management of MPE often focuses on symptomatic relief of symptoms and improving quality of life. We provide a review of the 2023 BTS guidance in relation to malignant pleural effusions and specific points on imaging and systemic anti-cancer treatment by concentrating on a hypothetical patient vignette. Full article

Objectives: Absorbable biomaterials as adjuvant therapy after thoracoscopy are sometimes used in clinical scenarios. With the prevalence of enhanced rapid recovery in thoracic surgery, drainless video-assisted thoracoscopy surgery (VATS) is often adopted by thoracic surgeons. Here, we discuss utilizing an absorbable biomaterial, Neoveil^TM (Polyglycolic Acid sheet), for drainless VATS to treat early lung cancer. Methods: This single-center retrospective study was conducted from January 2018 to December 2022 at the National Taiwan University Hospital. We included patients who underwent drainless VATS for early-stage non-small cell lung cancer (NSCLC) in our institute. Propensity analysis was used to minimize selection bias. Outcome measurements were in-hospital stay, operation time, rate of thoracocentesis or chest drain re-insertion, complication rate, and perioperative course. Results: During the study period, 158 lung cancer patients were performed with drainless VATS wedge resection. Among them, Neoveil for stapling line coverage was done in 72 patients, while 86 patients did not receive Neoveil. After propensity analysis, we had 58 patients using Neoveil after drainless thoracoscopic lung resection, compared fairly with 58 patients without Neoveil after the same procedure. The basic characteristics are comparable regarding age, gender, BMI, operation methods, and lung cancer stage after propensity matching. The in-hospital stay (3.2 days in the Neoveil group and 5.6 days in the non-Neoveil group) and operation time (95.7 min in the Neoveil group and 59.3 min in the non-Neoveil group) are significantly different (p = 0.0001). One versus four patients was noted for postoperative conversion chest drainage insertion in each group (p = 0.17). Neither late complications nor recurrence/metastasis occurred in both groups during the following. Conclusions: Based on our 5-year retrospective study, which is balanced with propensity analysis, drainless thoracoscopic surgery treating early lung cancer can be enhanced by Neoveil with faster recovery by reducing the hospital stay, though with longer operation time. Full article

Permanent pacemaker implantation is a low-risk procedure. However, complications may occur at a rate of around 4–8%. We present a case where initial implantation resulted in complications that could have been avoided by meticulous assessment of lead position in different projections and early post-procedure X-ray that would have delineated other serious complications. We present a case where the right ventricular lead was placed in the coronary sinus, which resulted in the loss of pacing capture with further syncope after the pacemaker implant. This was apparent in the post-procedure electrocardiogram (ECG) with right bundle branch pacing and the lead was repositioned in the right ventricular apex the following day. Furthermore, the patient was discharged home without a chest X-ray (CXR), and she represented a week later with a haemo-pneumothorax and pericardial effusion. A chest drain was placed and was discharged after a slow recovery following several complications that could have been avoidable. Full article

Background: The insertion of chest drains (CD) in trauma patients is a lifesaving, albeit high-risk intervention. Safe insertion of CD in settings where aids like ultrasound are not available relies on a landmark technique defining the so-called triangle of safety. The inferior margin of this triangle is identified by nipple height, which is thought to correspond to the fifth intercostal space (ICS). Training manikins are modeled after a lean male body and oftentimes insinuating jokes fuel uncertainty about the height of the nipple as a reliable landmark in female trauma patients. This study aims to prove that the nipple can be considered a safe landmark for CD insertion in women: even if larger breasts follow the force of gravity, it should not act towards the direction of the feet, but to the sides of the thorax in a flat-lying trauma patient. Methods: An online questionnaire was designed and distributed amongst female surgeons. Epidemiological data (age, nr of pregnancies, history of breastfeeding) was collected. Height, weight, and body mass index (BMI) were reported. Chest circumference and underbust girth were self-measured. The nipple position in relation to the ICS was measured by the women while lying in a supine position. Results: 237 female surgeons completed the questionnaire. Nine questionnaires were excluded due to incomplete data sets. 20 women were excluded due to previous breast surgery. Thus, 208 participants (or 416 nipples) were included in analysis. In supine position, both nipples were located in the 5th (±0.8) intercostal space. Age, BMI, height, weight, and status post-pregnancy had no significant impact on nipple position. Interestingly, a history of breastfeeding correlated with lower nipple position. Conclusions: The nipple is a safe landmark for identifying the correct insertion position of chest drains in supine-lying female trauma patients. Full article

Thoracostomy and chest tube placement are key procedures in treating pleural diseases involving the accumulation of fluids (e.g., malignant effusions, serous fluid, pus, or blood) or air (pneumothorax) in the pleural cavity. Initially described by Hippocrates and refined through the centuries, chest drainage achieved a historical milestone in the 19th century with the creation of closed drainage systems to prevent the entry of air into the pleural space and reduce infection risk. The introduction of plastic materials and the Heimlich valve further revolutionized chest tube design and function. Technological advancements led to the availability of various chest tube designs (straight, angled, and pig-tail) and drainage systems, including PVC and silicone tubes with radiopaque stripes for better radiological visualization. Modern chest drainage units can incorporate smart digital systems that monitor and graphically report pleural pressure and evacuated fluid/air, improving patient outcomes. Suction application via wall systems or portable digital devices enhances drainage efficacy, although careful regulation is needed to avoid complications such as re-expansion pulmonary edema or prolonged air leak. To prevent recurrent effusion, particularly due to malignancy, pleurodesis agents can be applied through the chest tube. In cases of non-expandable lung, maintaining a long-term chest drain may be the most appropriate approach and procedures such as the placement of an indwelling pleural catheter can significantly improve quality of life. Continued innovations and rigorous training ensure that chest tube insertion remains a cornerstone of effective pleural disease management. This review provides a comprehensive overview of the historical evolution and modern advancements in pleural drainage. By addressing both current technologies and procedural outcomes, it serves as a valuable resource for healthcare professionals aiming to optimize pleural disease management and patient care. Full article

Objectives: Coronary artery fistulas (CAFs) are rare congenital anomalies with an occurrence rate of 0.002–0.3%. The right coronary artery (RCA) is reportedly the most common site of origin of CAFs, but fistulas draining to the left atrium (LA) are rare. We presented a three-year-old boy with a symptomatic congenital RCA-to-LA fistula, which was successfully percutaneously occluded with an Amplatzer vascular plug 4 (AVP4). Case report: The diagnosis was made by echocardiography when he was two months old. During the follow-up period of 2 years, a progressive dilatation of the RCA and enlargement of the left ventricle was detected, so treatment for congestive heart failure was initiated. At the age of three, the patient presented with a history of occasional mild central chest pain and discomfort and mild dyspnea on exertion. On a 24 h ECG Holter monitor, the depression of ST segments was registered. CT angiography highlighted a large type B RCA fistula to the LA, which extended along the atrioventricular sulcus. The proximal RCA diameter was 7 mm. The fistula was tortuous, with segmental narrowing and three curves. Cardiac catheterization was performed across the right femoral artery on the three-year-old boy (body weight: 13 kg). Across the 4F Judkins right guiding catheter, an AVP4 of 5 mm was placed in the distal part of the CAF connected with the delivery cable. After 15 min, ECG changes were not registered, so the device was released. Immediate post-deployment angiography demonstrated complete CAF occlusion, with satisfying flow in the distal coronary artery. The patient was discharged after four days. In the short-term follow-up period, the boy was symptom-free. Conclusions: In our experience, given the existence of the left-to-left shunt and the more pronounced exercise-induced coronary steal phenomenon that occurs in medium-sized and large CAFs, occlusion is necessary to prevent the further progression of clinical signs and symptoms. Full article

Background/Objectives: Chest X-ray (CXR) is currently the most used investigation for clinical follow-up after major noncardiac thoracic surgery. This study explores the use of lung ultrasound (LUS) as an alternative to CXR in the postoperative management of patients who undergo major thoracic procedures. Methods: The patients in our cohort were monitored with both a CXR and a lung ultrasonography after surgery and the day after chest drain removal. The LUS was performed by a member of the medical staff of our unit who was blinded to both the images and the radiologist’s report of the CXR. Findings were compared between the two methods. Results: In the immediate postoperative evaluation, 280 patients were compared, finding general agreement between the two procedures at 84% (kappa statistic, 0.603). The LUS showed a sensibility of 84.1%, a specificity of 84.3%, a positive predictive value (PPV) of 60.9%, and a negative predictive value (NPV) of 94.8%. We evaluated 219 out of 280 patients in the postdrainage-removal setting due to technical issues. Concordance between the methods in the postdrainage-removal setting was 89% (kappa statistic, 0.761) with the LUS demonstrating an 82.2% sensibility, a 93.2% specificity, a PPV of 85.7%, and an NPV of 91.3%. Conclusions: The results of this study showed a substantial agreement between LUS and CXR, suggesting that the LUS could reduce the number of X rays in certain conditions. The high NPV allows for the exclusion of PNX and pleural effusion without the need to expose patients to radiation. Discrepancies were noted in cases of mild pneumothorax or modest pleural effusion, without altering the clinical approach. Full article

A 64-year-old man, who had no pre-existing health conditions, was admitted to the intensive care unit due to progressive shortness of breath resulting from COVID-19. Initially, the patient responded to non-invasive mechanical ventilation, which improved his breathing function. However, after six days, his respiratory function worsened significantly, requiring invasive ventilation. Out of nowhere, the person experienced spontaneous pneumomediastinum and extensive subcutaneous emphysema. The next day, a spontaneous pneumothorax occurred and was successfully drained later. It became evident that there was extensive subcutaneous emphysema also. The CT scan of the chest confirmed the presence of spontaneous pneumomediastinum, but it did not have any effect on the patient’s hemodynamics. The physicians performed a bronchoscopy and imaging with a contrast medium, which ruled out any lesions to the trachea or esophagus. No other issues related to the problem were identified during the examination. Unfortunately, microscopic bullae of interstitial emphysema, or micro air leaks, are visible when they are an adequate size on computed tomography. Recent literature and studies not available during the case report have shown that if the Macklin effect is detected on the baseline CT scan, it could predict the occurrence of pneumothorax or pneumomediastinum. Full article

Chest trauma is one of the most serious and difficult injuries, with various complications that can lead to ventilation–perfusion (V/Q) mismatch and systemic hypoxia. We are presenting a case of a 53-year-old male with no chronic therapy who was admitted to the Intensive Care Unit due to severe respiratory failure after chest trauma. He developed a right-sided pneumothorax, and then a thoracic drain was placed. On admission, the patient was hemodynamically unstable and tachypneic. He was intubated and mechanically ventilated, febrile (38.9 °C) and unconscious. A lung CT showed massive non-ventilated areas, predominantly in the right lung, guiding repeated therapeutic and diagnostic bronchoalveolar lavages. He was ventilated with PEEP of 10 cmH₂O with a FiO₂ of 0.6–0.8. Empirical broad-spectrum antimicrobial therapy was immediately initiated. Both high FiO₂ and moderate PEEP were maintained and adjusted according to the current blood gas values and oxygen saturation. He was weaned from mechanical ventilation, and non-invasive oxygenation was continued. After Stenotrophomonas maltophilia was identified and treated with sulfamethoxazole/trimethoprim, a regression of lung infiltrates was observed. In conclusion, both ventilatory and antibiotic therapy were needed to improve the oxygenation and outcome of the patient with S. maltophilia pneumonia and V/Q mismatch. Full article