Kenji Kawamukai

Does induction treatment increase the risk of morbidity and mortality after pneumonectomy? A multicentre case-matched analysis §

BACKGROUND The objective of this investigation was to compare postoperative morbidity and early and late mortality in patients after pneumonectomy for non-small-cell lung cancer (NSCLC) with or without induction neo-adjuvant therapy. METHODS This is an observational study performed on prospectively collected data at four tertiary referral centres (2000-2007). Of 225 pneumonectomies for NSCLC, 81 patients underwent neo-adjuvant chemotherapy. Several perioperative variables were used in identifying propensity score-matched pairs of patients with and without induction treatment. The matched groups were then compared in terms of morbidity, early (30-day or in-hospital) and 90-day mortality. RESULTS The overall cardiopulmonary morbidity, early mortality and 90-day mortality rates were 30% (67 patients), 7.1% (16 patients) and 9.8% (22 patients), respectively. Propensity score analysis yielded 56 well-matched pairs of patients with and without induction chemotherapy. The two groups had similar early and late mortality rates: four versus four (p=1) and seven versus seven (p=1), respectively. Moreover, the incidence of cardiopulmonary morbidity and bronchopleural fistula were also similar in both the groups: 19 versus 17 patients (Fishers exact test p=0.7) and two versus three patients (Fishers exact test, p=0.7), respectively. Twenty-one patients with induction chemo-radiotherapy were analysed separately and compared with well-matched counterparts without any induction treatment. No significant differences were identified in terms of early mortality (1 vs 0, p=1), 90-day mortality (1 vs 0, p=1), cardiopulmonary complications (5 vs 5, p=1) and bronchopleural fistula (1 vs 1, p=1). CONCLUSIONS Current regimens of induction treatment do not seem to increase the risk of morbidity, early mortality and late mortality after pneumonectomy in properly selected patients. This study warrants confirmation from future multicentre prospective randomised trials powered on early outcomes.

Combined pneumothorax and pneumoperitoneum following blunt trauma: an insidious diagnostic and therapeutic dilemma

Pneumoperitoneum following trauma usually indicates the presence of a perforated intra-abdominal viscus and the need for laparotomy.1 Other causes of a pneumoperitoneum demonstrate the alternative routes that air can take into the peritoneal cavity: through the abdominal wall, through the diaphragm, through the female genital tract, and through the retroperitoneum.2–5 By recognising that air may have taken one of the alternative routes into the peritoneal cavity, an unnecessary laparotomy may be avoided. Pneumoperitoneum has also been reported to be a complication of mechanical ventilation,6 likely related to air from the pleural cavity tracking into the peritoneum.7 8 We present two cases of blunt thoraco-abdominal trauma, with CT findings of massive pneumothorax with large amounts of abdominal free air. These cases show two different possibilities of localisation of intra-abdominal free air associated with traumatic pneumothorax. ### Case 1 A 21-year-old man was referred to our trauma centre from the casualty department of a local hospital, after falling and being repeatedly kicked by a horse. The patient was haemodynamically unstable at the scene (blood pressure 80/50 mm Hg), tachycardic (114 beats/min (bpm)), and breath sounds were absent on the right side and notably decreased on the left. At the casualty department he underwent immediate needle decompression of the right tension pneumothorax followed by left intercostal drain insertion. The abdomen was slightly distended and tender at palpation, and subcutaneous emphysema was palpable on the upper chest. Focused assessment with sonography for trauma (FAST) was limited by a large amount of intra-abdominal free air. The patient remained unstable after intercostal chest drain (ICD) insertion; he was intubated and referred to us …

Persistent late post-pneumonectomy spontaneous pneumothorax: a challenging case.

Post-pneumonectomy spontaneous pneumothorax is fortunately a very rare condition. We describe herein a late spontaneous right pneumothorax case occurring in a post-pneumonectomy patient and treated by thoracotomic bullectomy.

Acute postoperative cardiac herniation

Acute herniation of the heart is an uncommon complication in patients undergoing pneumonectomy with associated pericardial resection. We report the case of a postoperative cardiac herniation after a right extrapleural pneumonectomy following neoadjuvant chemotherapy for malignant pleural mesothelioma. After surgery the patient was completely asymptomatic, but a postoperative chest X-ray revealed unexpected massive dextrocardia. The patient was immediately brought back to the operating room: a cardiac herniation was found to be caused by a partial dehiscence of the pericardial prosthesis suture. The defect was repaired without consequences.

Treatment of an acquired esophageal-bibronchial benign fistula using an original combination of techniques

We report on the successful surgical treatment of an esophageal-bibronchial fistula originating from an iatrogenic mediastinal abscess. Endoscopic treatment had been excluded due to the extensive damage to the right main stem bronchus wall. The surgical treatment was carried out as follows: 1) Endoscopic stenting of the left main bronchus with a self-expanding metallic stent followed by selective left main bronchus intubation; 2) Laparotomic harvesting of the omentum pedicled on both gastro-epiploic vessels; 3) Right thoracotomy, complete dissection of both main bronchi and esophageal wall at the site of the leakage; 4) Harvesting of a pericardial vascularized graft; 5) Deployment of a self-expanding metallic stent from the surgical field into the right main stem bronchus; 6) Reconstruction of the right bronchus wall with the pericardial patch; 7) Positioning a T-tube in the esophageal leak; and 8) Intrathoracic transposition of the omental graft for buttressing all sutures and potential leakage points. The postoperative course was uneventful from a surgical point of view and the patient recovered completely.

Trauma-induced “Macklin effect” with pneumothorax and large pneumomediastinum, disguised by allergy

A 56-year-old man presented spontaneously to the Emergency Department complaining of facial and neck oedema after assumption of nonsteroidal anti-inflammatory drugs (NSAIDS). The triage nurse assigned the patient to Accident & Emergency (A&E) doctor as probable allergic reaction to NSAIDS. Chest X-ray (CXR), ordered after 24 hours, revealed a huge subcutaneous chest and neck emphysema without clearly visible pneumothorax. Subsequent chest CT scan showed a small left pneumothorax and a large amount of air in the mediastinum. The patient was conservatively treated since he was eupnoeic and hemodynamically stable. The pathophysiology of pneumomediastinum was first described by Macklin in 1939. The Macklin effect involves alveolar ruptures with air dissection along bronchovascular sheaths to the mediastinum. In this case the patient did not report in his history a recent blunt thoracic trauma and the initial suspicion of an allergic reaction has prevented physicians to immediately achieve the correct diagnosis.

Pendulum knife on a stabbed heart

A 46-year-old woman was brought to the emergency department after having been found stabbed at home. A 25 cm long knife was stuck on the anterior left chest, over the cardiac area approximately between the sternum and the midclavicular line on the fifth intercostal space. Two further deep wounds were on the left chest 3–4 cm above the knife along the midclavicular line and on the …

Mediastinal germ cell tumour with massive pulmonary involvement

Multimodality treatment, with chemotherapy and surgery, is potentially curative in case of non-seminomatous germ cell tumours. The authors present the case of a primitive mediastinal GTC with bilateral lung metastases. The patient was treated with five cycles of chemotherapy. Restaging showed reduction of the extent and of 18 FDG intake and β-HCG serum levels. The patient underwent two-step surgical excision of the tumours: mediastinal lesion and 35 lung metastases were resected by a right thoracotomy and 39 metastases were removed by a left thoracotomy. Histology showed absence of viable tumour in all the specimens. Twelve months after surgery the patient is free of disease.

Bronchoscopic management of prolonged air leak

Broncho-pleural fistula (BPF) is an atypical communication between the tracheobronchial tree and the alveolar/pleural space, with prolonged air leak (PAL). BPF is frequent and related to significant morbidity, prolonged length of hospital stay, and mortality. Nevertheless, in about 10%, more than 5 days of an air leak is considered a PAL, accounted for significant morbidity. Endobronchial valve is a novel device for the PAL management with minimal morbidity if related to surgical repairs. While it is suggested that surgical treatment should be undertaken when possible, endobronchial valves should be recommended as a therapeutic choice in high-risk patients. Placement techniques remain operator and patient friendly and allow the procedure to be performed with relative ease. Prospectively conducted, randomised, controlled clinical trials are needed where valve treatment is compared with other bronchoscopic techniques, surgical procedures, or both.

Uniportal video assisted thoracic surgery: hilar dissection

In recent years, the uniportal approach has become one of the most exciting and innovative developments in minimally invasive thoracic surgery. While the debate over its supposed advantages, learning curve and complexity continues, this manuscript explores the technical aspects of performing the hilar dissection for a lobectomy via the uniportal approach. Using a step-by-step narration, surgical details and key tips and tricks are laid out for the beginner hoping to clarify basic steps of the technique.