Roy Thomas Temes

Air embolus complicating transthoracic percutaneous needle biopsy.

Transthoracic percutaneous needle biopsy has become popular for evaluation of pulmonary nodules. However, it is a procedure with morbidity and mortality that is not negligible. In this article, we report massive air embolus complicating needle biopsy in a patient with amyloidosis. A negative biopsy does not exclude malignancy, and if surgical excision will be performed regardless of the result, preoperative assessment using this technique may not be necessary.

Lung biopsy: Is it necessary?

OBJECTIVE Lung biopsy is associated with substantial mortality rates. We reviewed our experience with this operation, primarily in patients with immunocompetence, to determine whether the results justify the continued performance of this procedure. METHODS We conducted a retrospective review of all diagnostic lung biopsies performed at 3 university-affiliated hospitals between July 1, 1992, and December 31, 1998. RESULTS There were 75 patients: 25 patients were treated electively, 17 were treated on an urgent basis, 27 patients on an emergency basis, and the urgency was unclear in 6 patients. Significant beneficial therapeutic changes were made in 15 of 25 elective procedures (60%), in 16 of 17 urgent procedures (94%), and in 11 of 27 emergency procedures (41%; P =.001). Significant beneficial therapeutic changes consisted of immunosuppression in 13 of 15 (87%) patients treated on an elective basis, in 9 of 16 (56%) treated on an urgent basis, and in 9 of 11 (82%) treated on an emergency basis in whom therapy was altered (P =.14). Operative death was 0 of 25 for elective operations (0%), 3 of 17 for urgent operations (18%), and 14 of 26 for emergency operations (54%). Multivariable analysis of operative death showed urgency to be the only significant predictor of death (P =.002). CONCLUSIONS In patients with immunocompetence, elective and urgent lung biopsies have acceptable operative mortality rates and frequently result in important beneficial therapeutic changes. Consequently biopsies are appropriate in these patients. Emergency biopsies are associated with high operative mortality rates and rarely result in a therapeutic change other than immunosuppression. These patients should not undergo lung biopsy if they are in stable condition and should be treated empirically with immunosuppression without operation if their condition is deteriorating.

RESECTION OF A SOLITARY PULMONARY ARTERIOVENOUS MALFORMATION BY VIDEO-ASSISTED THORACIC SURGERY

Pulmonary arteriovenous malformation (PAVM) is an unusual tumor of the lung. It produces direct connections between pulmonary arterial and venous vessels, resulting in right-to-left shunts. Surgical resection offers definitive cure, but transcatheter ablation is used more often because of lower morbidity and mortality rates. The advent of minimally invasive surgical techniques offers the advantage of both treatments: definitive therapy with minimal morbidity and mortality rates. We report a case of this unusual tumor successfully treated with video-assisted thoracoscopic resection (VATS). Clinical summary. A 37-year-old man had visual disturbances and dizziness. He also complained of cough, shortness of breath, and decreased exercise tolerance. A magnetic resonance image of the brain showed an occipital infarct. A chest radiograph showed a right lower lobe density. A computed tomographic (CT) scan of the thorax revealed a 4-cm welldefined mass in the right lower lobe of the lung supplied by large vessels (Fig 1). A tagged red cell perfusion-imaging scan documented a 14% right-to-left shunt (normal, <5%). Echocardiographic bubble study confirmed the shunt (Fig 2). The patient underwent uneventful VATS and wedge resection of the PAVM. Pathologic examination showed a benign PAVM. Pulmonary angiography, tagged red cell scan, and echocardiography were normal after operation (Fig 3). He continues to do well 4 months later. Discussion. PAVMs are unusual tumors of the lung, which occur spontaneously or in diseases such as hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome) or hepatic cirrhosis. 1 On CT scan they are diagnosed by their large feeding vessels. 2 They result in right-to-left shunting with dyspnea, fatigue, hypoxemia, and cyanosis. 3 Stroke or cerebral abscess may result from paradoxic embolization. The treatment goals are obliteration of the PAVM to resolve symptoms and prevent complications. Options for treatment include transcatheter embolization or surgical resection. Transcatheter embolization with balloons or stainless steel

Esophageal rupture after regional anesthesia: Report of two cases

Esophageal perforation after anesthesia is rare. It is usually secondary to esophageal instrumentation. Only one case of barogenic rupture after regional anesthesia has been reported. We report two additional cases and present possible mechanisms for this unusual entity. Neither patient had anatomic abnormalities by history or preoperative endoscopy. However, both patients and the previously reported patient had esophageal dysmotility resulting from advanced age, alcoholism, intraoperative medications, and preexisting disease. Each patient experienced at least one episode of emesis with subsequent perforation of the distal one third of the esophagus. The previously reported patient died; both of our patients underwent successful surgical repair and are alive 2 years later. Intraoperative or postoperative emesis in patients with esophageal dysmotility appears to be the principal factor causing esophageal rupture after regional anesthesia. Prevention of nausea and vomiting and recognition of this high-risk population may minimize this complication in the future.

Intrapulmonary lymph nodes masquerading as renal cell carcinoma metastases

Clinically apparent intrapulmonary lymph nodes are rare but may be incorrectly diagnosed as pulmonary metastatic disease. We report on a 65-year-old man who presented with a left renal mass and left lower lobe pulmonary nodules that were interpreted radiographically to be consistent with metastatic disease. Surgical pathologic examination confirmed intrapulmonary lymph nodes and a Stage II renal cell carcinoma. Failure to diagnose intrapulmonary lymph nodes may result in erroneous diagnosis of metastatic disease and preclude potentially curative treatment.

Internal fixation of high tracheal stents

A technique for internal fixation of a silicone elastomer tracheal stent is described. This technique allows the use of a short stent in situations where complex stent placement otherwise would be necessary. The procedure was used successfully to manage a postresection stricture in the subglottic trachea.