Complex use of ultrasound in the diagnosis and treatment of surgical diseases of the lung and pleura

Since 1980 the N.N. Burdenko Faculty Surgical clinic, I.M. Sechenov Moscow Medical Academy, has been using a combination of high- and low-frequency ultrasounds for the diagnosis and treatment of surgical diseases of lung and pleura in 156 patients for the diagnosis of pleuritis of various genesis, in 40 patients for transthoracic aspiration biopsy of lung tumors in the preoperative period, in 156 patients for pleural puncture and drainage, in 40 patients for the intraoperative differential diagnosis of peripheral lung tumors and for the inspection of hematogenic and lymphogenic metastatic areas, in 100 patients for intraoperative prophylaxis, and in 20 patients for the treatment of acute postoperative pleural empyema. Ultrasound was demonstrated to be of high informative value in diagnosing different pleuritis. Transthoracic aspiration biopsy was shown to have some advantages over standard methods: use of needle catheters for pleural puncture permits one to avoid serious complications (pneumothorax, bleeding, etc). Ultrasound was used in intraoperative diagnosis of peripheral lung tumors for the first time. The use of low-frequency ultrasound for the intraoperative prevention of acute postoperative pleural empyemas promotes reliable sanitation of the pleural cavity, as confirmed by bacteriologic control data. Timely rethoracotomies with low-frequency ultrasound treatment of the pleura promote more rapid inflammation elimination in the pleural cavity and prevents irreversible complications.     

Ultrasonic technologies in diagnosis and treatment of patients with surgical diseases of lungs and pleura

The results of complex examination and treatment of 376 patients with different diseases of the lungs and pleura were analyzed. High-frequency ultrasound was used in 256 patients for diagnosis of lungs and pleura surgical diseases, 412 ultrasonic examinations were performed. Intraoperative treatment of pleura with low-frequency ultrasound was carried out 134 times for prophylaxis and treatment of acute postoperative pleura empyema in 120 patients operated on for malignant tumors and chronic purulent diseases of the lungs. High efficacy of high-frequency ultrasound for diagnosis of pleura empyema, diffuse and encapsulated pleurisy is demonstrated. Ultrasound-assisted pleural punctures an transthoracic aspiration biopsies permit to avoid complications. Ultrasonic examination of the lungs during surgery in patient suspected of lung cancer permits to study tumor structure. Treatment of pleura with low-frequency ultrasound and combination of this method with photodynamic therapy promote reliable sanation of pleural cavity. Limited rethoracotomy and treatment of pleura with low-frequency ultrasound is the method of choice in the treatment of acute postoperative empyema when there is no effect of conservative treatment.     

Low-frequency ultrasonics in the surgical treatment of pulmonary echinococcosis

The article discusses the results of surgical treatment of 29 patients suffering from hydatid disease of the lungs with the use of low-frequency ultrasonics for rendering harmless the germinal elements so as to prevent recurrence of the disease. It was demonstrated that low-frequency ultrasonics causes death of the germinal elements of the parasite in sonication both directly in the cyst and in the residual cavity of the fibrous capsule of the echinococcus and in the pleural cavity. The methods of application of low-frequency ultrasonics in surgical treatment of various forms of hydatid disease of the lungs are described. In examination of patients in postoperative periods of 6 months to 2 years no recurrences of the disease were revealed.     

The surgical treatment of echinococcosis of the diaphragmatic surface of the liver]

The results of surgical treatment of 628 patients aged 15-76 years operated on for echinococcosis of diaphragmatic surface of the liver have been analysed for period from 1976 to 1996. 333 patients had complicated echinococcosis, 124 combined pathology of other organs. Methods which have been applied for diagnosis of echinococcosis of the liver and its complications are described. Details of surgical treatment of the echinococcosis of the diaphragmatic surface of the liver are elucidated in time course aspects, as a staged treatment, during which various factors were used for antiparasitic treatment of cystic cavity as well as various methods of elimination of the residual cavity. Problems concerning application of laser and plasmatic scalpel during various stages of the operation, as well as low-intensity lasers and low-frequency ultrasound during the operation and in postoperative period are considered. Postoperative complications were detected in 99 (15.8%) patients, lethal outcomes were in 5 (0.8%) cases.     

Surgical outcome of lung cancer patients with carcinomatous pleuritis

In sporadic though non-anecdotal series, long-term survival has been reported for patients operated on for lung cancer with secondary carcinomatous pleuritis. In a retrospective study, we review the outcomes of 24 surgical patients (20 treated with standard lung resection +/- pleurectomy and 4 with extended pleuropneumonectomy) out of 48 individuals affected by pleural spread before or at thoracotomy. We observed a 16.6% major complication rate with no operative mortality; 5-year and median survival were 20% and 21 months, respectively. Time of diagnostic (pre- vs intra/postoperative) or pattern (effusion vs dissemination) of pleural disease, and type of resection (standard vs extended) did not seem to influence the prognosis, while an adenocarcinoma histotype, completeness of excision and N(0-1) were favourable prognostic indicators. Since most (90%) of these IIIB stages are usually associated with N(2-3) and/or unresectable tumour, it would seem reasonable to employ neo-adjuvant treatment as the first approach, reserving surgical treatment to responders. Multicentre studies are necessary to better determine which subgroup of patients with malignant pleuritis can most benefit from surgical therapy.     

Plasma technologies in surgery of pulmonary echinococcosis

178 patients were operated over 18 years for pulmonary echinococcosis, 100 of them with standard methods, 78--with plasma technologies (surgical device SUPR-2M). Close echinococcectomy was performed in 22.5% patients, open--in 69.1%, combination of these operations--in 8.4% patients. Plasma technologies were used at pneumolysis, cysts section, antiparasitic treatment of residual cavities, fibrous capsule resection (pericystectomy) or cystpericystectomy, marginal resection of the lung with cyst, bronchotomy, sanation of pleural cavity, zone of operation and margins of operative wound. It is demonstrated that postoperative complications were seen in 34% patients operated by standard methods and in 8.9% patients operated with plasma technologies, lethal outcomes were in 2 (2%) and 1 (1.3%) patients, respectively. Plasma technologies permitted to reduce postoperative complications rate 3.8 times and postoperative treatment by 9.8 bed days or by 45.8%. Long-term results were studied in 61 (78.2%) operated patients followed from 1 month to 7 years, there were no recurrence of echinococcosis.     

Prevention of bronchial fistula and empyema after resection and removal of the lung

Pulmonectomies in 231 patients and resections of a lung in 320 patients were followed by the development of bronchial fistulas in 33 patients (5.9%): after pneumonectomy--in 17 patients (7.3%) and after lobe- and bilobectomy in 16 patients (5%). Empyema of the pleura was noted in 20 patients (3.6%): in 12 patients (5.2%) and 8 patients (2.5%) correspondingly. Seventeen of 53 patients with these complications died. The use of a manual method of suturing the bronchus without a stump with the local application of fibrinogen, complex bronchological sanitation and intraoperative bronchofibroscopy (drainage of the pleural cavity after pneumonectomy with the following filling of the cavity with an antiseptic solution and formation of the selective pneumoperitoneum) allowed to decrease the incidence of bronchial fistulas in 102 patients to 2.9%, and empyema of the pleura--to 1.9%.     

Surgical treatment of pulmonary hydatid cysts in children

OBJECTIVE: Hydatid disease is a parasitosis and endemic in many sheepraising areas; it is still an important health problem in Turkey. We report our experience with childhood hydatid cyst and discuss the concepts of treatment. METHODS: The clinical courses of 128 children with thoracic and liver hydatid cyst operated on from 1994 to 2000 were reviewed. The group consisted of 71 boys and 57 girls aged from 8 months to 16 years. Intact cysts were found in 144 patients and ruptured cysts in 68. RESULTS: In the postoperative course we have encountered 20 perioperative complications in 16 patients. The most common complication was residual pleural space and delayed air leakage, which occurred in 9 patients. There was no early death. CONCLUSION: Surgery is the treatment of choice for most patients with pulmonary hydatid disease. The aim of surgery is evacuation of the cyst, removal of the endocyst, and management of the residual cavity. Conservative surgical methods that preserve lung parenchyma should be preferred.     

The endoscopic operations by solid thoracic tumors in children

20 patients were operated thoracoscopically on the cause of the solid tumors of the pleural cavity. Patients were aged from 1 day of life to 17 years. Minimal size of the tumor was 3.1×3.5×4.0 sm; maximal 10×10×20 sm. The control group was created of 22 children with thoracic tumors, operated via thoracotomy. The postoperative period and outcomes were statistically better among patients, treated thoracoscopically.     

Preserved Pleural Integrity Provides Better Respiratory Function and Pain Score after Coronary Surgery

Abstract   Background and Aim: Patients undergoing surgical procedures through median sternotomy have reduced pulmonary function in the postoperative period. Our study was designed to evaluate the effect of pleural integrity in terms of respiratory functions and pain score after coronary bypass procedures. Methods: In a randomized, prospective study we evaluated 320 patients in two groups. Group I (n = 160) patients were the patients whose pleural cavity was intact while internal mammary artery (IMA) harvesting, and in group II (n = 160) the pleural cavity of the patients was opened. They matched in terms of postoperative respiratory functions and pain score. Results: FEV1 (%) and FEV1/FVC levels at the postoperative fifth day were significantly lower in group II (I = 71.5 ± 4.9 vs. II = 63.5 ± 8.3 and I = 24.1 vs. II = 22.1), respectively (p < 0.05). The rate of postoperative pleural effusions and atelectasis at the postoperative fifth day were significantly higher in group II (I = 35%, 15% vs. II = 48%, 35%), respectively (p < 0.05). The pain score was higher in group II at postoperative fifth day. Conclusions: All patients undergoing cardiac surgery suffer deterioration in pulmonary functions. Pleurotomy seems to compound this with increased rates of atelectasis and pleural effusions. Moreover, preserving pleural integrity provides beneficial effects on pain score after coronary operations especially in the early postoperative period.     

The primary postponed radical surgical treatment of acute suppurative paraproctitis]

The method of primarily postponed radical surgical treatment of acute purulent paraproctitis consists in puncture of the abscess, introduction of a double-channel drain, and continuous drop irrigation of the cavity for 1-2 days with antiseptic solutions and active aspiration for preoperative management. When the inflammatory process abates, fistulochromography is conducted and a radical operation is carried out on the same day with excision of the inner opening of rectal fistula. The method makes it possible to combine two operations in one stage which are undertaken in one third of patients in routine surgical treatment of acute paraproctitis. The described method shortens the period of treatment to 14-15 days and improves the immediate and long-term results. Eight patients were operated on with a good outcome.     

Supraomohyoid neck dissection in cancer of the oral cavity.

BACKGROUND: In oral cavity cancer, supraomohyoid neck dissection (SOHND) is becoming more popular for patients with N0 and N1 disease in the neck. The aim of this study was to assess the value of this surgical procedure. METHODS: The study included 237 previously untreated patients with oral cavity cancer. The neck treatment consisted of SOHND or functional neck dissection (FND). One hundred sixty patients underwent postoperative radiation therapy. Survival probabilities, neck recurrences, and distant metastases were analyzed according to the surgical procedure. RESULTS: For patients having undergone SOHND, the 5-year survival probabilities were 70.2% and 76.5% in N0 and N1 necks, respectively. The neck recurrence rate in SOHND was 2%. CONCLUSIONS: SOHND is an effective method of treatment for the clinically negative neck in patients with squamous cell carcinoma of the oral cavity. It also proves efficient, in conjunction with postoperative radiotherapy, for control of neck metastases in selected patients.     

Relevance of infection in children with urachal cysts

OBJECTIVE: To assess the role of infection in the management of children with urachal cysts. METHODS: A retrospective study on 10 children with urachal cysts operated on over an 11-year period (from 1987 to 1998) was performed. Uncomplicated urachal cysts were found in 2 children who underwent primary cyst removal. The remaining 8 were admitted with severe sepsis due to the presence of a urachal abscess; they were managed by a staged approach including percutaneous drainage and delayed cyst removal. The diagnosis of urachal cyst was readily made by ultrasound in all the 10 patients (100%). In 1 patient with urachal abscess, computed tomography provided additional information. RESULTS: The postoperative course was uneventful in 9 of 10 children (90%). A 5-year-old female patient developed peritonitis following urachal abscess rupture into the peritoneal cavity, which resulted in additional surgery and prolonged hospitalization. CONCLUSIONS: (1) Ultrasound is an excellent diagnostic tool for patients with urachal cysts. (2) A renal screening ultrasound must be included in the preoperative work-up. (3) A thorough urological assessment is indicated in patients with abnormal renal ultrasound of recurrent urinary infections. (4) At present, a staged surgical procedure still remains the most effective surgical option in children with urachal cyst.     

Diagnosis and removal of foreign bodies of the thoracic cavity using thoracoscopy

The author analysed the use of thoracoscopy in 12 patients with radiopaque and radiolucent foreign bodies in the pleural cavity, lung, mediastinum, myocardium, and diaphragm. The indications for the examination were specified: (1) foreign body in the pleural, cavity or its existence suspected; (2) indistinct character of an intrathoracic foreign body and injury inflicted by it to the viscera; (3) specification of surgical tactics and method for removal of the foreign body and rational surgical approach. Thoracoscopy made it possible to detect not only foreign bodies of different character, but the damages caused by them to the viscera, and the complications. Foreign bodies were removed during thoracoscopy in two thirds of cases.     

Use of the ultrasound investigation after operations on the thoracic cavity in children

The author describes the experience with using ultrasound investigation (USI) for detection of complications and dynamic control of the state of organs of the thoracic cavity in the postoperative period in 174 children aged from 2 days to 14 years. The findings of USI were used to determine the strategy of treatment in the postoperative period: expedience of pleural puncture, repeated thoracoscopic sanitation for empyema of the pleura etc. In 3 children hematoma was revealed in the bed of the ablated tumor of the mediastinum, in 1 case--pneumothorax after lung hydatidectomy, in 1 infant after operation a recurrent diaphragmatic hernia was revealed by USI. Thus, echography is thought to be an informative harmless method of diagnosis of complications after operations on the thoracic cavity in children allowing to successfully control the state of the pleural cavity, lungs, and mediastinum and to determine the rational strategy of treatment.     

Surgical approach in bilateral and combined echinococcosis of the lung

One hundred and two patients aged from 4 to 65 years with echinococcosis were treated. Solitary cysts in both lungs were diagnosed in 69 patients, multiple cysts -- in 33 patients. In 10 cases small and middle cysts were in the upper parts of both lungs. These patients underwent one-stage operation consisting in lateral thoracotomy, removing of the cyst from one lung, incision of retrosternal mediastinal pleura, removing of the cyst from the second lung, drainage of pleural cavity. Fifteen patients with combined echinococcosis of the upper lobe of the right lung and liver were operated with another one-stage surgical method through thoracotomy in the third and sixth or seventh intercostal space. These methods are characterized by low traumaticity, decreased number of postoperative complications and hospital stay.     

Hydatid cyst of the liver with intrathoracic rupture.

In the last 10 years we have operated on 33 cases of hydatid cyst of the liver with intrathoracic rupture. Twenty-one out of 33 cases ruptured into bronchi, in seven the rupture affected the pleural cavity, and in six simultaneous rupture into the bronchus and pleural cavity occurred. Laboratory tests were not carried out in all cases. The Casoni intradermal test was carried out in 23 cases and was positive in 18. A liver scan was performed in 10 and was positive in all. Conservative operations were carried out in 22 patients. In these the hepatic cavity was evacuated and separately drained. This was followed by suturing the diaphragmatic rupture and also closing the bronchial opening if present. Lung resections were performed in 11 out of 33 cases. In eight lobectomy was carried out and in three segmental resections. Resection was necessary when suppuration and bronchiectatic changes affected the lung. Ruptured cyst into the pleural cavity requires emergency thoracotomy after the anaphylactic shock is over. Removal of the parasite, re-expansion of the lung, and drainage of the pleural and hepatic cavities is necessary. Immediate and late complications occurred in 13 patients. In two postoperative haemorrhage occurred and in two postoperative empyema developed. Recurrent haemoptysis was seen in five, persistent bile fistula in one, and dissemination of hydatid cyst in three. In the remaining 20 cases there was no complication. Operative mortality was nil.     

Does pleural lavage cytology before thoracic closure predict both patient's prognosis and site of cancer recurrence after resection of esophageal cancer?

BACKGROUND: Operative manipulation occasionally exfoliates and spreads cancer cells in the surgical field, and it is a matter of concern whether the exfoliated cancer cells actually affect the patient's prognosis and sites of cancer recurrence. METHODS: In 240 patients with esophageal cancers, lavage cytology (LC) of the right pleural cavity was performed before and after esophageal resection combined with regional lymphadenectomy. The cytologic results were compared with the pathologic factors associated with cancer extension, postoperative survival, and cause of surgical failure. RESULTS: Only 3 patients (1.3%) were LC positive before resection. Of the 237 LC-negative patients, LC was also negative after resection in 215 patients (90.7%) (LC-/-), but LC became positive after resection in 22 patients (9.3%) (LC-/+). The 3-year survival rate was 0% in the LC-/+ group versus 65% in the LC-/- group, and the median survival rates were 10.9 months and 25.0 months, respectively (P <.0001). Multivariate analysis revealed that LC-/+ was an independent prognostic factor (P =.0331), along with nodal involvement and depth of cancer invasion. However, there were no significant differences in the sites of cancer recurrence between the 2 groups. Only 1 patient was found to develop the first recurrence in the pleural cavity. The LC-/+ group had a higher incidence of bulky lymph-node metastasis (P =.0009). CONCLUSIONS: Pleural LC after resection of esophageal cancer seems to be a prognostic indicator of overall recurrence, but not necessarily in the pleural cavity. Patients with a positive LC after resection may benefit most by effective systemic adjuvant chemotherapy.     

Mediastinal echinococcosis

Among 29,875 autopsies 59 cases of mediastinal echinococcosis were revealed. Among 4178 patients with thoracic echinococcosis 55 patients had mediastinal echinococcosis. All the patients were operated, most of them underwent ideal ecinococcectomy. Intraoperative prophylaxis of echinococcosis was performed: plearal cavity was treated by low-frequency ultrasound and glycerin. 7 examined patients demonstrated reduction of immune and phagocytosis indices in blood (DC3+, CD4+, CD8+, CD16+, CD21+). Increase of immunoglobulines A, M, G and circulating immune complexes was revealed. Reactions of scolexprecipitation and lymphocytes antigen-fixing were positive.     

The role of thoracoscopy in the treatment of pleural empyema in children

Background The treatment of empyema with pleural drainage is a widely accepted surgical procedure. Currently, thoracoscopy often is used to treat this disease in some thoracic surgery centers. This report aims to present the authors’ experience with the treatment of pleural empyema and the benefits of thoracoscopy. Methods From 1997 to 2005, 49 children with a diagnosis of pleural empyema were treated by means of thoracoscopy in the authors’ department. The study group consisted of 21 girls and 28 boys, ages 1 to 17 years (mean age, 9.2 years). Thoracoscopic cleaning and drainage of the pleural cavity was performed for all the patients. Results Intraoperatively, stage I empyema was recognized in 7 children (14.3%), stage II in 30 children (61.2%), and stage III in 12 children (24.5%). Very good results were obtained for all the patients. There were no intra- or postoperative major complications. The drainage time was less than 5 days for 63.3% of the children. In the remaining group of patients, drainage exceeded 8 days only for 16.3%. The postoperative time was short. Emptying of the pleural cavity and full lung decompression were achieved in all cases. In four cases, pleural biopsy showed TB, which enabled early proper treatment. Conclusions Thoracoscopy can offer good visualization and cleansing of the empyema chambers, establishing efficient drainage even for patients with advanced stages of pleural empyema. Thoracoscopy enables collection of material not only for bacteriologic, but also for histopathologic examination. The method is minimally invasive, and risk for complication is comparable with that for classical thorax drainage.