Pulmonary resection using a total endoscopic robotic video-assisted approach

We have developed a robotic video-assisted thoracoscopic technique (RVATS) for lung resection that could encourage broader use of minimally invasive lobectomy. During December 2006 to September 2010, RVATS was performed in 200 consecutive patients (90 women, 110 men) with the da Vinci Surgical System (Intuitive Surgical, Inc, Sunnyvale, CA). Pulmonary resection was performed through ports without the need for a utility incision. Data on patients' perioperative results were collected retrospectively. Robotic video-assisted pulmonary resection was accomplished in 197 of 200 patients. A total of 154 patients underwent lobectomy; 4 patients required bilobectomy, and 35 patients underwent segmentectomy. Three patients underwent a sleeve lobectomy, and 3 patients had an en-bloc resection with lobectomy. One patient received a left pneumonectomy. Three patients required conversion to a thoracotomy. The median operative time was 90 minutes. The median length of hospital stay was 3 days. 60-day mortality and morbidity was 2% and 26%, respectively. RVATS lung resection is technically feasible, safe, and results indicate the procedure is associated with reduced length of stay, low morbidity, and mortality.     

Exacerbation of Secondary Pulmonary Hypertension by Flat Chest after Lung Transplantation

A 40-year-old woman with idiopathic pleuroparenchymal fibroelastosis (IPPFE) and flat chest underwent left single lung transplantation (SLT). Although she had developed over-systemic pulmonary arterial pressure (PAP) at transplantation, it was alleviated. However, her PAP gradually increased again. Her transplanted lung was well-inflated, but progression of fibrosis in her right native lung appeared to have caused a mediastinal shift, and her flat chest caused obstruction of the outflow tract of the pulmonary vein. She died of heart failure and associated infection 1.5 years after transplantation. An autopsy confirmed irreversible pulmonary arterial and venous changes in the transplanted lung, suggestive of chronic pressure overload. The flat chest associated with IPPFE can affect pulmonary circulation after SLT.     

Noninvasive Differential Diagnosis of Pulmonary Nodules Using the Standardized Uptake Value Index

Objectives: We previously showed that the standardized uptake value (SUV) index, which was defined as the ratio of the maximum SUV of the tumor to mean SUV of the liver, was a surrogate marker of lung cancer aggressiveness. In this study of patients with pulmonary nodules (PNs), we explored whether the SUV index could be used to differentiate small malignant from small benign PNsMethods: A total of 284 patients with solitary PNs ≤2 cm in size underwent positron emission tomography/computed tomography and surgery. The associations between pathological findings and clinical factors were evaluated.Results: The median SUV indices of lung cancer, metastatic PNs and benign nodules were 1.2, 1.5, and 0.6, respectively (P <0.01). A SUV index cut-off value of 1.2 was used to differentiate benign from malignant nodules. When patients were grouped according to SUV index cut-off values of <1.2 or ≥1.2, the following cases were false-negative: lung adenocarcinoma (P <0.01), kidney as primary site (P <0.01), and metastatic PNs with long disease-free survival (P = 0.02).Conclusions: As a noninvasive diagnostic marker, the SUV index was found to be useful for differentiating benign from malignant small PNs.     

Pulmonary malakoplakia secondary to Rhodococcus equi infection mimicking a lung neoplasm in a lung transplant recipient

Pulmonary masses occasionally occur after lung transplantation and vary in etiology, which includes malignant and benign conditions, such as infection. Here, we report a case of a patient presenting with a lung mass 3 years after lung transplant. To our knowledge, this is the first described case of pulmonary malakoplakia due to Rhodococcus equi infection in an allograft post–lung transplantation. This case outlines the challenges of differentiating benign from malignant masses after transplantation.     

Impact of Left Ventricular Diastolic Dysfunction on Lung Transplantation Outcome in Patients With Pulmonary Arterial Hypertension

Diastolic dysfunction may influence perioperative outcome, early graft function, and long‐term survival. We compared the outcomes of double lung transplantation (DLTx) for patients with pulmonary arterial hypertension (PAH) with preoperative left ventricular (LV) diastolic dysfunction with the outcomes of patients without diastolic dysfunction. Of 116 consecutive patients with PAH (who underwent transplantation between January 1995 and December 2013), 44 met our inclusion and exclusion criteria. Fourteen (31.8%) patients with diastolic dysfunction pretransplantation had a higher body mass index (29 [IQR 21.5–32.6] vs 22.4 [IQR 19.9–25.3] kg/m²) and mean pulmonary arterial pressure (54.6 ± 10 mmHg vs 47 ± 11.3 mmHg) and right atrial pressure (16.5 ± 5.2 mmHg vs 10.6 ± 5.2 mmHg). The patients received extracorporeal life support more frequently (33% vs 7% [p = 0.02]), had worse APACHE II scores (21.7 ± 7.4 vs 15.3 ± 5.3 [p = 0.02]), and a trend toward worse ventilator‐free days (2.5 [IQR 6.5–32.5] vs 17 [IQR 3–23] [p = 0.08]). There was no effect on development of primary graft dysfunction or intensive care unit/hospital survival. One‐year survival was worse (hazard ratio [HR] 4.45, 95% confidence interval [CI] 1.3–22, p = 0.02). Diastolic dysfunction was the only variable that correlated with overall survival (HR 5.4, 95% CI 1.3–22, p = 0.02). Diastolic dysfunction leads to early postoperative morbidity and worse survival in patients with PAH after DLTx.     

Postoperative Acute Pulmonary Embolism Following Pulmonary Resections

Postoperative acute pulmonary embolism after pulmonary resections is highly fatal complication. Many literatures have documented cancer to be the highest risk factor for acute pulmonary embolism after pulmonary resections. Early diagnosis of acute pulmonary embolism is highly recommended and computed tomographic pulmonary angiography is the gold standard in diagnosis of acute pulmonary embolism. Anticoagulants and thrombolytic therapy have shown a great success in treatment of acute pulmonary embolism. Surgical therapies (embolectomy and inferior vena cava filter replacement) proved to be lifesaving but many literatures favored medical therapy as the first choice. Prophylaxis pre and post operation is highly recommended, because there were statistical significant results in different studies which supported the use of prophylaxis in prevention of acute pulmonary embolism.Having reviewed satisfactory number of literatures, it is suggested that thoroughly preoperative assessment of patient conditions, determining their risk factors complicating to pulmonary embolism and the use of appropriate prophylaxis measures are the key options to the successful minimization or eradication of acute pulmonary embolism after lung resections.     

Pulmonary expression of inducible heme-oxygenase after ischemia/reperfusion of the lower extremities in rats

BACKGROUND: Expression of inducible heme-oxygenase (HO-1) has been shown to be increased in various inflammatory disorders, which may confer a protective role. The aim of our study was to assess pulmonary expression of HO-1 after ischemia/reperfusion (I/R) of the lower limbs in rats. MATERIALS AND METHODS: We compared three groups of rats (n = 5/group): one Sham group, and two I/R groups (aorta cross-clamped for 2 h followed by 2 h of reperfusion), one of which pre-treated with Zn-protoporphyrin (Zn-PP), a competitive inhibitor of HO (50 micromol/kg, i.p.). At the end of experiment, lungs were harvested for determination of HO activity and HO-1 expression by Western blot and immunohistochemistry. Lung injury was assessed by bronchoalveolar lavage, histological study, and determination of the lung Evans Blue dye content, an index of microvascular permeability. RESULTS: I/R of the lower limbs was responsible for acute lung injury (ALI), characterized by neutrophilic infiltration (87 +/- 20 x 10(3) neutrophils/mm(3), Sham group versus 191 +/- 38 x 10(3) neutrophils/mm(3), I/R group; P < 0.002) and an increase in lung Evans blue dye content: (74 +/- 6 microg/g, Sham group versus 122 +/- 48 microg/g, I/R group; P < 0.05). Pre-treatment with Zn-PP further increases the Evans Blue content (122 +/- 48 microg/g, I/R group versus 179 +/- 23 microg/g Zn-PP group P < 0.05) and the neutrophilic infiltration. Pulmonary heme-oxygenase activity, and HO-1 content were increased after I/R. (10.5 +/- 12 pmol bilirubin/mg protein/h, Sham group versus 101.2 +/- 66 pmol bilirubin/mg protein/h, I/R group; P < 0.02). Immunohistochemistry revealed that the expression of HO-1 was mainly localized to inflammatory cells. CONCLUSIONS: ALI following I/R of the lower limbs in rats is associated with an increase of pulmonary expression of HO-1, inhibition of this expression increase the severity of ALI.     

Pulmonary aspiration

Pulmonary aspiration is defined as the inhalation of oropharyngeal or gastric content into the airway below the vocal cords. The mechanisms of injury related to aspiration can be divided into three groups: particle related, acid related and bacterial. Clinical signs suggestive of aspiration are: diffuse rales, wheezing, tachypnoea and low grade pyrexia. Investigations include: fibreoptic bronchoscopy, bronchoalveolar lavage and protected brush specimens. Imaging used includes chest X-ray and computed tomography. Initial management consists of administration of 100% oxygen and strategies to minimise the risk of further aspirate contaminating the airway. The decision to continue with surgery depends on the extent of the aspiration, the patient's premorbid condition and the urgency of the procedure. Elective surgery is most likely to be abandoned or postponed. In the emergency situation modification of the surgical procedure to one that is less complex or lengthy should be considered. The patient in ICU receives supportive treatment. Ventilatory lung protective strategies should be used to limit further lung injury. Seventy per cent of aspiration pneumonitis do not develop bacterial superinfection so antibiotics are not needed unless confirmed by bronchial culture.     

Pulmonary Sequestration

Nine cases of pulmonary s.questration are presented. Pre-operative angiographic demonstration of the anomalous arterial supply was performed in 5 cases. In 4 cases, where selective angiography of the anomalous artery was carried out, even the venous drainage was clearly visualized. The diagnostic and therapeutic value of angiography is stressed.     

Pulmonary blastoma

We describe a resected pulmonary blastoma in an 84-year-old male, the oldest of previously reported patients. A chest X-ray showed a 2 cm-sized abnormal shadow in the left lung field. Five months later computed tomography demonstrated a well-demarcated heterogenous mass, measuring 12 cm in diameter, in the left lower lobe of the lung. This mass was diagnosed as a carcinoma using echo-guided percutaneous biopsy. The patient underwent a left lower lobectomy. The resected specimen revealed the tumor to be a pulmonary blastoma arising from lung tissue. Preoperative diagnosis of pulmonary blastoma is extremely difficult because of the histological heterogeneity of tumor. Since it has been noted that pulmonary blastoma rapidly progresses in a short period of time, surgical treatment should be undertaken as quickly as possible when such a tumor is suspected.     

Pulmonary rehabilitation

Pulmonary rehabilitation (PR) has been shown to improve dyspnea, exercise capacity and health-related quality of life in patients with chronic obstructive pulmonary disease (COPD). PR has also shown benefits in diseases other than COPD but the level of evidence is lower. The fundamental components of PR programs are muscle training, education and chest physiotherapy. Occupational therapy, psychosocial support and nutritional intervention should also be considered. Home programs have been shown to be as effective as hospital therapy. The duration of rehabilitation programs should not be less than 8 weeks or 20 sessions. Early initiation of PR, even during exacerbations, has proven safe and effective. The use of oxygen or noninvasive ventilation during training is controversial and dependent on the patient's situation. At present, the best strategy for maintaining the benefits of PR in the long term is unknown. Longer PR programs or telemedicine could play a key role in extending the results obtained.