Clinical and pathological characteristics of spontaneous pneumothorax in women: a 25-year single-institutional experience

Objectives

Accumulating evidence suggests that spontaneous pneumothorax (SP) in women, while relatively rare, has higher rates of post-treatment recurrence than in men. Our aim was to further elucidate the clinical and pathological characteristics of SP in women.

Methods

We retrospectively reviewed 59 female patients with no known underlying lung disease undergoing surgery for their SP from January 1990 to December 2015. We divided the study population into those older than or equal to 50 years and those younger than 50 years, the latter of which was further subdivided into catamenial and non-catamenial pneumothorax.

Results

Among the study population, 11 (18.6%) had catamenial pneumothorax, 40 (67.8%) had non-catamenial pneumothorax, and 8 (13.6%) were older than 50 years. Pathological diagnoses of catamenial pneumothorax were diaphragmatic endometriosis (n?=?4), emphysematous bullae (n?=?4), solitary pulmonary capillary hemangiomatosis (SPCH, n?=?2), and hematoma (n?=?1). By contrast, emphysematous blebs/bullae accounted for all but one case of non-catamenial pneumothorax and all cases in the ≥?50 years age group. Catamenial pneumothorax showed a significantly higher postoperative recurrence rate compared to non-catamenial pneumothorax (p?=?0.0043). The 2-year cumulative ipsilateral recurrence rates of catamenial, non-catamenial, and ≥?50 years age group were 39.4, 13.8, and 14.3%, respectively.

Conclusions

Catamenial pneumothorax affected approximately 20% of female patients undergoing surgery for spontaneous pneumothorax with no underlying lung disease and showed a significantly higher postoperative recurrence rate. Diaphragmatic endometriosis and subpleural blebs/bullae were common pathological findings in catamenial pneumothorax, but SPCH might be a possible pathological diagnosis of catamenial pneumothorax.

     

Vats Versus Axillary Minithoracotomy in the Management of the Second Episode of Spontaneous Pneumothorax: Cost–Benefit Analysis

Background

Video-assisted thoracic surgery (VATS) was considered the gold standard approach in recurrent spontaneous pneumothorax, with unanimous consensus of opinions. The cost-effectiveness analysis in the surgical treatment of recurrence of primary spontaneous pneumothorax (PSP) was carried out comparing VATS with muscle-sparing axillary minithoracotomy (MSAM).

Methods

Between July 2006 and October 2012 we treated 56 patients with a second episode of PSP by VATS or open approach. Time of intervention, prolonged air leaks, duration of pleural drainage, length of hospitalization, and long-term morbidity were evaluated, establishing the relationship between costs and quality-adjusted life for each technique.

Results

The assessment of pain and threshold of tenderness was more favorable in VATS in respect to MSAM during the 5 years of follow-up (p = 0.004 and <0.001 at 1st year; p = 0.006 and <0.002 at 5th year). The minimally invasive method was less expensive than axillary minithoracotomy (2443.44 € vs. 3170.80 €). The quality-adjusted life expectancy of VATS was better than that of MSAM (57.00 vs. 49.2 at 60 months) as well as the quality-adjusted life year (0.03 at 1st year and 0.13 at 5th year). Incremental cost per life year gained of VATS versus MSAM was between 24,245.33 € (1st year) and 5776.31 € (5th year), making it advantageous at 3rd, 4th, and 5th years.

Conclusions

VATS compared to MSAM in the treatment of a second episode of PSP ensured undoubted clinical advantages associated with significant cost savings.

     

Outcome and risk factors of recurrence after thoracoscopic bullectomy in young adults with primary spontaneous pneumothorax

Purpose

To investigate the risk factors of recurrence of pneumothorax following thoracoscopic bullectomy in young adults.

Methods

Between January, 2005 and September, 2015, 167 patients aged ≤40 years underwent initial thoracoscopic bullectomy for primary spontaneous pneumothorax (PSP) at our hospital. Recurrence-free probability was calculated from the date of surgery to recurrence or last follow-up, using the Kaplan–Meier method.

Results

Sixteen (9.6%) of the 167 patients suffered a recurrence (collective total, 16 recurrences). The recurrence-free intervals were 3–107 months (median 25.8 months), and the 5-year recurrence-free probability was 85.9%. Multivariate Cox analysis demonstrated that age ≤23 years (p = 0.029) and a history of ipsilateral pneumothorax before surgery (p = 0.029) were significantly associated with higher risk of recurrence. The 5-year recurrence-free probability was 72.3% for patients aged ≤23 years and a history of ipsilateral pneumothorax before surgery and 94.1% for those with neither of these factors (p = 0.001). Recurrence developed within 3 years after surgery in 14 of the 16 patients.

Conclusions

Patients ≤23 years of age with a history of ipsilateral pneumothorax before surgery are at significantly high risk of its recurrence, frequently within 3 years; thus, the risk of postoperative recurrence of a pneumothorax must be kept in mind.

     

Recurrent Primary Spontaneous Pneumothorax is Common Following Chest Tube and Conservative Treatment

Introduction

Previous studies on primary spontaneous pneumothorax reported variable recurrence rates, but they were based on heterogeneous patient populations including secondary pneumothorax. We investigated young patients with primary spontaneous pneumothorax exclusively and used a national registry to track readmissions and calculate independent predictors of recurrence.

Methods

A prospective cohort study of consecutive young patients who were admitted over a 5-year period with their first episode of primary spontaneous pneumothorax and treated conservatively with a chest tube. Baseline characteristics were obtained from questionnaires presented on admittance. All patients were discharged with fully expanded lungs on chest radiography. Patient charts were identified in the national electronic patient registry for detailed information on readmissions due to recurrent spontaneous pneumothorax.

Results

We included 234 patients. Male/female = ratio 5/1. After a median observation period of 3.6 years (range 1–6 years), recurrent pneumothorax was observed in 54 %. Ipsilateral recurrence was the most common (79 %) but 30 % also experienced contralateral pneumothorax during the study period. Females had a significantly higher age at debut (p < 0.01) and experienced significantly more recurrences over time (p < 0.01). Low body weight (<60 kg) was an independent predictor of recurrence and patients with repeated recurrences were significantly younger at debut (p = 0.01).

Conclusions

Primary spontaneous pneumothorax in younger patients with their first episode had a much higher recurrence rate than previously reported. Every doctor who treats patients with primary spontaneous pneumothorax should be aware and patients informed.

     

Covering the staple line with polyglycolic acid sheet versus oxidized regenerated cellulose mesh after thoracoscopic bullectomy for primary spontaneous pneumothorax

Objective

The aim of this study was to compare coverage with oxidized regenerated cellulose mesh and that with polyglycolic acid sheet to decrease the incidence of postoperative recurrent pneumothorax.

Methods

From August 2010 to August 2014, a total of 112 patients with primary spontaneous pneumothorax undergoing thoracoscopic bullectomy were enrolled. We compared the clinicopathological characteristics between recurrent and non-recurrent cases and examined their association with the material used for visceral pleural coverage: polyglycolic acid sheet versus oxidized regenerated cellulose mesh.

Results

57 patients underwent thoracoscopic bullectomy plus coverage using oxidized regenerated cellulose mesh and 55 underwent thoracoscopic bullectomy plus coverage using polyglycolic acid sheet. The recurrence rate among all patients was 13.3%. No severe postoperative complications were observed in either group. There were no significant differences in the perioperative outcomes. However, the postoperative recurrence rate was significantly higher in the oxidized regenerated cellulose mesh group than in the polyglycolic acid sheet group (22.8 vs 3.6%).

Conclusions

Our results suggest that coverage with oxidized regerated cellulose mesh was not superior to coverage with polyglycolic acid sheet for postoperative recurrent pneumothorax.

     

First Episode of Spontaneous Pneumothorax: CT-based Scoring to Select Patients for Early Surgery

Background

Although recurrence of primary spontaneous pneumothorax (PSP) is frequent, guidelines do not routinely recommend surgery after first presentation. A CT-based lung dystrophy severity score (DSS) has recently been proposed to predict recurrence following conservative therapy. This study compares the DSS in surgically and conservatively treated patients.

Methods

This is a retrospective analysis of first episode PSP patients, comparing video-assisted thoracic surgery (VATS; group A) to conservative treatment with or without chest drainage (group B). CT scans were reviewed for blebs or bullae, and patients were assigned DSS values and stratified into risk groups (low and high-grade). Primary end point was ipsilateral or contralateral recurrence.

Results

Fifty-six patients were included, 33 received VATS and 23 conservative treatment. In total, 37.5 % experienced recurrence, with a 5-year estimated recurrence rate of 40.7 % (group A: 13.3 %; group B: 73.9 %; p < 0.001). In group B, detection of any dystrophic lesions resulted in significantly higher 5-year recurrence rates (86.7 vs. 50.0 %; p = 0.03), there was no significant difference in group A (17.7 vs. 7.7 %; p = 0.50). Greater DSS values correlated with higher 5-year recurrence rates in group B (p = 0.02), but not in group A (p = 0.90). Comparing low- and high-grade patients in group B resulted in a significant 5-year recurrence rate of 53.8 versus 100 % (p = 0.023).

Conclusions

The DSS is useful to indicate VATS after the first episode. For routine application, assigning patients to low- and high-grade groups seems most practical. We recommend CT-evaluation for every PSP patient and early surgery for those with lesions exceeding one bleb. After VATS, the preoperative DSS is not beneficial in predicting recurrence.

     

Feasibility of single-incision thoracoscopic surgery using a modified chest wall pulley for primary spontaneous pneumothorax: a propensity score matching analysis

Purpose

Recently, single-incision thoracoscopic surgery (SITS) has been recognized as a favorable treatment choice for primary spontaneous pneumothorax (PSP) compared with conventional three-port video-assisted thoracoscopic surgery (VATS). However, conventional SITS bullectomy often results in collisions with surgical devices. Therefore, we devised a method of SITS using a chest wall pulley for lung excision (PulLE) and modified PulLE (mPulLE) system, which substitutes threads to eliminate such collisions. We compared the mPulLE system with conventional procedures using propensity score matching (PSM) to adjust for patient backgrounds.

Methods

Using PSM, we evaluated the surgical results of 210 PSP patients who underwent VATS, including mPulLE (n?=?23) and three-port VATS (n?=?102), at our institution between January 2010 and August 2016.

Results

We selected 17 mPulLE cases and 17 three-port VATS. There were no marked differences between the groups in the patient backgrounds or surgical results. However, there was a significant difference between the mPulLE cases and the three-port VATS cases in the operative time (71.7?±?15.7 vs. 85.9?±?25.5 min, respectively, P?=?0.0388) and the number of autosutures used (3.6?±?1.2 vs. 4.5?±?1.2, respectively, P?=?0.0178).

Conclusion

The surgical results of mPulLE in patients with PSP with multiple lesions were equivalent to those achieved with three-port VATS under the same conditions.

     

Submucosal Hematoma of the Sigmoid Colon as a Complication of Anticoagulation Treatment

Background

Anticoagulation therapy after coronary stent implantation is necessary and crucial for patients with severe coronary heart disease. Submucosal bleeding of the colon is an infrequent complication of anticoagulants.

Methods

TWe present the case of a 70-year-old woman with spontaneous submucosal hematoma and active bleeding of her sigmoid colon due to anticoagulants after intracoronary stenting.

Results

This patient underwent a timely surgical operation. Treated by our experienced multidisciplinary team, her recovery was smooth without any other major complications.

Conclusions

Surgical intervention is an appropriate therapy for patients with intractable bleeding.

     

Total aortic arch replacement using hypothermic circulatory arrest with antegrade selective cerebral perfusion: are there cerebral deficits other than frank stroke?

Background

It is controversial whether cerebral deficits other than frank stroke develop after total aortic arch replacement using hypothermic circulatory arrest (HCA) with antegrade selective cerebral perfusion (SCP).

Objectives

We investigated neuropsychological functions in patients who received total aortic arch replacement using deep HCA with SCP.

Methods

Eleven patients who underwent elective total arch replacement using deep HCA with antegrade SCP were included. Cognitive functions of the patients were evaluated at baseline, and 3 weeks and 6 months after the aortic arch surgery.

Results

The performance of cognitive tests did not change 3 weeks after surgery, except for the attention/calculation task of the Mini-Mental State Examination (MMSE). Six months after surgery, the decline in score for the attention/calculation task in the MMSE had reversed and the score for this task as well as for all other tests had returned to baseline levels.

Conclusion

Long-lasting cognitive deficits other than frank stroke may not develop after total arch replacement surgery using deep HCA with SCP.

     

Single lung transplantation for lymphangioleiomyomatosis: a single-center experience in Japan

Purpose

Lung transplantation is accepted as an effective modality for patients with end-stage pulmonary lymphangioleiomyomatosis (LAM). Generally, bilateral lung transplantation is preferred to single lung transplantation (SLT) for LAM because of native lung-related complications, such as pneumothorax and chylothorax. It remains controversial whether SLT is a suitable surgical option for LAM. The objective of this study was to evaluate the morbidity, mortality and outcome after SLT for LAM in a lung transplant center in Japan.

Methods

We reviewed the records of 29 patients who underwent SLT for LAM in our hospital between March, 2000 and November, 2017. The data collected included the pre-transplant demographics of recipients, surgical characteristics, complications, morbidity, mortality and survival after SLT for LAM.

Results

The most common complication after SLT for LAM was contralateral pneumothorax (n?=?7; 24.1%). Six of these recipients were treated successfully with chest-tube placement and none required surgery for the pneumothorax. The second-most common complication was chylous pleural effusion (n?=?6; 20.7%) and these recipients were all successfully treated by pleurodesis. The 5-year survival rate after SLT for LAM was 79.5%.

Conclusion

LAM-related complications after SLT for this disease can be managed. SLT is a treatment option and may improve access to lung transplantation for patients with end-stage LAM.

     

Total thyroidectomy followed by bilateral pneumothorax and pneumomediastinum with simultaneous damage to the recurrent laryngeal nerve: Report of a case

Background

Thyroidectomy is a common and safe surgical procedure which is typically associated with low morbidity. Pneumomediastinum and pneumothorax following cervical emphysema after thyroidectomy have been rarely mentioned, and the mechanism implicated in these two conditions is uncertain.

Case report

We present a 53-year-old male who experienced extensive emphysema, bilateral pneumothorax and pneumomediastinum following total thyroidectomy under general anaesthesia with damage to the left recurrent laryngeal nerve. The diagnostic evaluation, management, and the possible aetiology of these complications are discussed.

Results

We believe that the pneumothorax was not the result of the damage to the airway or larynx. We assume that the pneumothorax was caused by operative damage to the neck or was due to anatomical reasons. It is also feasible that air entered through the thinned fascial layer owing to the surgery. Another hypothesis is the possibility that the pneumothorax was caused by mid-surgery damage, given the difficulties in surgical manoeuvering. This hypothesis is further reinforced when considering the synchronous damage to the left recurrent laryngeal nerve.

Conclusion

The complications observed in this case after total thyroidectomy with invasive manoeuvres were very rare. However, they were suspected early and the patient recovered without further problems.

     

Endovaskuläre Therapie genetisch bedingter Aortenerkrankungen

Background

The most important structural proteins of the vascular wall are collagen and elastin. Genetically linked connective tissue diseases lead to degeneration and aneurysm formation, spontaneous dissection or rupture of arteries. The most well-known are Marfan syndrome, vascular Ehlers-Danlos syndrome type IV, Loeys-Dietz syndrome and familial aortic aneurysms and dissections.

Objective

This review article adresses the current status of endovascular treatment options for important connective tissue diseases.

Material and methods

Evaluation of currently available randomized studies and register data.

Results

The therapy of choice for patients who are mostly affected at a young age is primarily conservative or open repair. There is only limited evidence for endovascular aortic repair (EVAR) of abdominal aneurysms or thoracic endovascular aortic repair (TEVAR).

Conclusion

The progression of the disease with dilatation leads to secondary endoleakage and high reintervention rates with uncertain long-term results. For this reason there is currently consensus that EVAR and TEVAR should be limited to justified exceptional cases and emergency situations in patients with genetically linked aortic diseases.

     

Recurrent Laryngeal Nerve Monitoring and Rocuronium: A Selective Sugammadex Reversal Protocol

Background

The use of neuromuscular blocking agents may affect intraoperative neuromonitoring during thyroid surgery. A selective neuromuscular recovery protocol was evaluated in a retrospective cohort study during human thyroid neural monitoring surgery.

Methods

One hundred and twenty-five consecutive patients undergoing thyroidectomy with intraoperative neuromonitoring followed a selective neuromuscular block recovery protocol—single intubating dose of rocuronium followed by sugammadex if needed at the first vagal stimulation (V1).

Results

Data from 120 of 125 patients could be analysed. Fifteen (12.5%) patients needed sugammadex reversal to obtain an EMG response at the first vagal stimulation (V1). In the remaining 105 patients, spontaneous recovery of rocuronium-induced neuromuscular block was sufficient for a successful first vagal stimulation (V1).

Conclusions

In patients undergoing thyroid surgery, routine reversal of rocuronium block with sugammadex is not mandatory for reliable intraoperative neuromonitoring. A selective neuromuscular block recovery approach may be a valuable and more cost-efficient alternative to routine reversal.

     

Komplikationsmanagement im Internet Marketing

Background

New patients come more and more often over the internet; therefore internet marketing plays an increasingly important role.

Question

How can physicians build an effective internet marketing strategy and avoid complications?

Method

Selection and authorization of a reputable agency.

Results

New customer acquisition through high visibility in the internet, at the same time increasing the image and awareness.

Conclusions

In the overall “marketing mix” internet marketing has become indispensable to physicians who want to be successful. Those who are well positioned in Google are well known by their target audience and thus receive a higher response.

     

Cam morphology and inguinal pathologies: is there a possible connection?

Background

To analyse the prevalences of the cam and pincer morphologies in a cohort of patients with groin pain syndrome caused by inguinal pathologies.

Materials and methods

Forty-four patients (40 men and 4 women) who suffered from groin pain syndrome were enrolled in the study. All the patients were radiographically and clinically evaluated following a standardised protocol established by the First Groin Pain Syndrome Italian Consensus Conference on Terminology, Clinical Evaluation and Imaging Assessment in Groin Pain in Athlete. Subsequently, all of the subjects underwent a laparoscopic repair of the posterior inguinal wall.

Results

The study demonstrated an association between the cam morphology and inguinal pathologies in 88.6% of the cases (39 subjects). This relationship may be explained by noting that the cam morphology leads to biomechanical stress at the posterior inguinal wall level.

Conclusions

Athletic subjects who present the cam morphology may be considered a population at risk of developing inguinal pathologies.

Level of evidence

Level IV, Observational cross-sectional study.

     

Patellaformen

Background

Patella height is discussed as a possible factor in the development of osteoarthritis of the knee.

Methods

PubMed literature search

Results

Contradictory results are found in the literature.

Conclusion

According to the literature, there is currently no evidence that abnormal patella height can induce osteoarthritis of the knee.

     

Harnröhrenrekonstruktion bei vorausgegangener Hypospadieoperation

Background

The tasks involved in reconstructing the urethra after failed hypospadias repair range from correction of a trivial meatal stenosis to reconstruction of the entire anterior urethra.

Objectives

To describe pathological findings in the urethra after failed hypospadias repair and the respective surgical methods used for their correction.

Materials and methods

The various pathological findings after unsuccessful hypospadias surgery are classified according to their location and complexity.

Results

The general rules of reconstruction that should be applied in each particular situation are described.

Conclusions

Successful reconstruction of the urethra in patients with failed hypospadias surgery requires experience and good knowledge of the anatomy of the normal and hypospadic urethra and penis. Mastery of plastic surgical techniques and profound knowledge of the various surgical methods of hypospadias surgery are essential.

     

Successful Surgical Treatment of Intractable Chylous Ascites Using the Lymphatic Cable Flap: A Retrospective Review Study

Objective

For evaluation of a novel surgical procedure for the treatment of chylous ascites.

Summary background data

Chylous ascites is a debilitating condition associated with high morbidity and mortality rates. At least one-third of patients are refractory to medical therapy and may warrant further treatment. Traditional methods involving ligation of lymphatic fistulas or small bowel resection do not address the basic pathophysiologic mechanism of the underlying obstruction, and identification of chyloperitoneal fistulas may be challenging.

Methods

A novel flap based on deep inferior epigastric vessels with its surrounding lymphatic fatty tissue was designed in this study and transferred into abdominal cavity, with anastomosis to the fourth jejunal vessels. Three consecutive cases with chylous ascites treated by this vascularized lymphatic cable transfer were retrospectively reviewed.

Results

All three patients recovered from chylous ascites after the lymphatic cable transfer and tolerated regular diet well, with follow-up of 3 years at least.

Conclusions

Lymphatic cable flap based on the deep inferior epigastric vessels could be a potential option for treatment of intractable chylous ascites, with safe and successful long-term outcomes in three consecutive patients. The proposed functional mechanism of the flap is bypass of the obstructed intra-abdominal lymphatics to an extraperitoneal route as well as local lymphangiogenesis.

     

Arthroskopische subakromiale Dekompression

Objective

Coracoacromial ligament release to widen the subacromial space, resection of the anterior undersurface of the acromion and, if needed, caudal exophytes at the acromioclavicular joint.

Indications

All types of outlet impingement after 3 months of conservative treatment.

Contraindications

Impingement syndrome with instability/muscular imbalance, massive rotator cuff tear, unstable os acromionale, posterior–superior impingement, joint infection, freezing phase of a secondary frozen shoulder.

Surgical technique

Lateral decubitus position with traction device for the arm. Diagnostic arthroscopy of the glenohumeral joint via standard portals. With arthroscope moved to the subacromial space, bursectomy, electrosurgical release of coracoacromial ligament, resection of acromial hook through standard posterior portal.

Postoperative management

Physiotherapy or self-exercises on postoperative day 1, pain-adapted analgesia to avoid shoulder stiffness.

Results

Several studies present positive long-term results compared to conservative treatment (and open acromioplasty) for partial rotator cuff tears and for elderly patients. With a 20-year follow-up, successful results have been achieved for all patients with isolated impingement syndrome.