Empyema thoracis

The actual incidence of empyema thoracis is still increasing worldwide and remains a clinical challenge with significant impact on public health; early recognition and prompt evaluation are of prime importance. Despite a lack of standardization of treatments, management should be planned according to stage, avoiding delays on referral. Exudative empyema (stage I) should be treated by aspiration or tube thoracostomy. Fibrinopurulent empyema (stage II) can be treated effectively by video-assisted thoracic surgery. Debridement and decortication are the main components of surgical treatment of stage III empyema. It is worthwhile to assess most cases by video-assisted thoracoscopy.     

超声引导下横突-胸膜中点阻滞与胸椎旁神经阻滞用于单孔胸腔镜手术后镇痛效果的比较

目的 比较超声引导下横突-胸膜中点阻滞(MTPB)与胸椎旁神经阻滞(TPVB)用于单孔胸腔镜手术术后镇痛的效果。
方法 选择择期行单孔胸腔镜手术患者80例,男36例,女44例,年龄18～65岁,BMI 19～28 kg/m²,ASA Ⅰ―Ⅲ级。采用随机数字表法分为MTPB组（M组）和TPVB组（P组）,每组40例。手术结束后M组行超声引导下MTPB,P组行TPVB,两组均注射0.5%罗哌卡因15 ml。两组患者术后均采用PCIA。记录神经阻滞操作时间、穿刺深度,记录术后2、6、12、24、48 h安静和咳嗽时VAS疼痛评分,记录镇痛泵首次按压时间、总按压次数、舒芬太尼使用量和补救镇痛例数,记录穿刺相关并发症、镇痛不良反应发生情况。
结果 与P组比较,M组神经阻滞操作时间明显缩短（P<0.05）,进针深度明显变浅（P<0.05）。术后2、6、12、24、48 h两组安静和咳嗽时VAS疼痛评分差异无统计学意义。两组患者术后镇痛泵首次按压时间、总按压次数、舒芬太尼用量和补救镇痛率差异无统计学意义。两组患者术后恶心、呕吐等不良反应差异无统计学意义。
结论 MTPB或TPVB联合术后PCIA应用于单孔胸腔镜手术患者,术后均可取得良好的镇痛效果,但MTPB操作简单、安全,可作为单孔胸腔镜手术患者术后镇痛方案的选择。     

Surgical Treatment of Hydatidothorax Series of 79 Cases

Objective: A retrospective review of 79 cases of ruptured intrapleural pulmonary hydatid cysts. We analyse and evaluate our experience in the surgical treatment of this complication.

Materials and Methods: In a ten-year period, from 1990 to 1999, 79 patients were operated on in our service for intrapleural rupture of a pulmonary hydatid cyst. There were 51 males and 28 females with a mean age of 35.4 years. The diagnosis was established on the basis of different clinical signs and imaging studies.

Surgical approach consisted of a posterolateral thoracotomy in all cases. After decortication, different procedures were performed on the pulmonary lesions according to the importance of lung destruction.

Results: Radical resections were done in 48 cases, including lobectomies (15), segmentectomies (33) and conservative treatment: simple capitonnage and bronchial fistula closure (31).

Postoperative complications occurred in 8 cases (10.1%), including one pyothorax, one haemothorax, one prolonged air leak, two pneumonias and two wound infections.

There was one postoperative death, by respiratory failure. Ninety-five percent (95%) of patients were free of recurrence of thoracic hydatid disease in a follow-up ranging from 1 to 10 years (mean: 5.4 years).

Conclusion: Hydatid cysts of the lung should be treated before complications occur, particularly intrapleural rupture because it considerably increases morbidity.     

Multiple calcifying fibrous pseudotumors of the pleura: ultrastructural analysis provides insight on mechanism of dissemination

ABSTRACT

Calcifying fibrous pseudotumor (CFP) is a rare, benign soft tissue tumor that may uncommonly arise in the pleura. These tumors can show multifocal dissemination across the pleural surface, but the mechanism underlying this dissemination is unclear. Review of previously reported cases of pleural CFP demonstrates a strong predilection for basal and diaphragmatic pleural surfaces, and a significantly higher rate of multifocality compared with other locations. We present a 59-year-old male with multiple CFP of the pleura. Reactive-appearing adhesions spanning the pleural surfaces were present, and by electron microscopy, were involved by tumor. We suggest this is the likely mode of dissemination across the pleural surfaces.     

结核性胸膜炎胸液中纤维蛋白原含量对胸膜肥厚及粘连形成的影响

目的　探讨结核性渗出性胸膜炎胸腔积液纤维蛋白原含量与胸膜肥厚、粘连的关系。方法117例初治结核性渗出性胸膜炎患者按胸腔积液纤维蛋白原含量从低到高分为A、B、C 3组 ,治疗过程中和治疗后测定胸膜厚度 ,评估胸膜粘连发生率。结果 治疗过程中胸膜厚度 :A组与B组比较 (t=2 .5 7,P<0.05 )有显著性差异 ,A组与C组比较 (t=7.15 ,P<0 .0 1)有显著差异性 ,B组与C组比较 (t=2.46 ,P<0 .0 5 )有显著性差异 ;胸膜粘连发生率 :A组与B组比较 (χ²=3.5 1,P>0.05 )无显著性差异 ,A组与C组比较 (χ²=9.87,P<0 .01)有显著性差异 ,B组与C组比较 (χ²=4 .5 1,P<0 .0 5 )有显著性差异。治疗结束时胸膜厚度 :A组与B组比较 (t=1.4 5 ,P>0 .0 5 )无显著性差异 ,A组与C组比较 (t=3.4 6 ,P<0.01)有显著性差异 ,B组与C组比较 (t=2 .89,P<0 .0 1)有显著性差异 ;胸膜粘连发生率 :A组与B组比较 (χ²=0 .10 ,P>0 .0 5 )无显著性差异 ,A组与C组比较 (χ²=4 .36 ,P<0.05)有显著性差异 ,B组与C组比较 (χ²=7.4 9,P<0 .0 1)有显著性差异。结论 胸液纤维蛋白原含量可影响胸膜肥厚度与胸膜粘连发生率。     

Primary pleural precursor B‐Cell lymphoblastic lymphoma

Intrathoracic lymphoblastic lymphoma (LBL) is classically of T‐cell lineage, but these cases of pleural B‐cell LBL suggest that this is not always the case. Despite the clinical challenges involved every attempt should be made to secure a biopsy and histological diagnosis, as we move into an era of lineage‐directed therapies.     

Pneumothorax and insertion of a chest drain

A pneumothorax occurs when the visceral or parietal pleura is breached and air enters the pleural space. This leads to loss of the negative intrapleural pressure and lung collapse. Pneumothoraces may be classified into ‘simple’, ‘tension’ or ‘open’ according to the underlying pathophysiology. A chest radiograph is essential in diagnosis and management. Tension pneumothorax is a medical emergency, relieved initially with needle thoracentesis, but treated definitively with a chest drain. The latter is inserted in all cases where aspiration is unsuccessful in controlling symptoms in a simple pneumothorax. A thoracic surgical opinion should be sought if there is persistent air leak from the drain or the lung fails to re-expand after three days.A chest drain is used to drain air, blood, fluid or pus from the pleural space. Proper attention should be paid to patient preparation, which should include full asepsis, appropriate patient positioning, and application of National Patient Safety Agency recommendations. A chest drain is usually inserted under local anaesthesia in the ‘safe triangle’ in the lateral chest wall using blunt dissection. The drains should not be clamped in cases of pneumothorax, and the drainage bottle should always be kept below the level of the patient’s chest.