Pleuroperitoneal communication with liver cirrhosis and chronic kidney disease needed hemodialysis successfully treated by video-assisted thoracoscopic surgery; report of a case

A 59-year-old man treated with hemodialysis for liver cirhhosis and chronic kidney disease developed right pleural effusion and ascites. Ascites always decreased after thoracocentesis for pleural effusion. In spite of repeated treatment with chest tube drainage, massive pleural effusion reappeared. Under the diagnosis of pleuroperitoneal communication, surgical repair of the diaphragm by video assisted thoracoscopic surgery (VATS) were performed. Bulla and pin hole were found and they were resected and sutured. Surgery was safely and successfully accomplished though the patient had Child-Pugh B liver cirhhosis. Pleural effusion disappeared after surgery.     

Life expectancy of patients with malignant pleural effusion treated with video-assisted thoracoscopic talc pleurodesis

The aim of the current study was to analyse postoperative complications and survival after video-assisted thoracoscopic (VATS) talc pleurodesis for malignant pleural effusion. All patients with morphologically proven malignant pleural effusion who underwent VATS talc pleurodesis from November 1995 to November 2002 were included in retrospective analysis. VATS was performed in general anaesthesia and 5 g of asbestos-free talc was insufflated into the pleural cavity. Postoperative pleural drainage was used until fluid output was less than 100 ml/24 h. Ninety-eight patients (28 male and 70 female) with mean age 59.6 (range 18-82) years were included. Thirteen patients had a bilateral pleural effusion. The most common primary cancer sites were lung (30 cases), breast (25) and ovarium (11). Average duration of the operation was 46 (range 10-120) min. Median duration of postoperative drainage was 3 (range 1-20) days and postoperative hospitalisation 7 (range 3-70) days. Twenty-eight patients had postoperative complications (fever in 17 cases). In seven cases pleurodesis was ineffective. Median survival was 8.4 months. Six-, 12- and 24-month survival was 58% (95% CI [0.47-0.67]), 39% [0.29-0.49] and 20% [0.12-0.29], respectively. Survival data after VATS talc pleurodesis advocate use of this invasive treatment method despite the advanced stage of cancer.     

Simultaneous bilateral decortications via video-assisted thoracic surgery for bilateral empyema

IntroductionBilateral empyema is a rare and life-threatening condition that is difficult to treat. We herein report a case of bilateral empyema that was treated with simultaneous bilateral decortications via video-assisted thoracic surgery (VATS).Presentation of caseA 38-year-old female complained of chest pain, dyspnea, and high grade fever lasting two weeks. Computed tomography revealed bilateral notching pleural effusion and pneumonia with atelectasis. Bilateral thoracic drainage was performed. From the right chest, white pus was drained, and Streptococcus anginosus was identified. The left drainage fluid was serous, and no bacteria were identified. We diagnosed the patient with right empyema and left para-pneumonic effusion consequent to pneumonia. Because conservative therapies could not resolve the inflammatory findings, simultaneous bilateral VATS decortications were performed. Both thoracic cavities had loculated pleural effusion. In contrast to the preoperative findings, white pus was found in not only the right, but also the left thoracic cavity. She had an uncomplicated postoperative course and recovered.DiscussionBilateral empyema that has developed to the fibrinopleural phase is difficult to treat with drains alone. Bilateral VATS decortications helped to make a definitive diagnosis and treat both sides simultaneously.ConclusionSimultaneous bilateral VATS decortications should be considered as a feasible and effective procedure for bilateral empyema that is refractory to medical treatment.     

肺癌伴恶性胸水的外科治疗

目的 探讨既消除胸水、治疗胸膜病变,又切除或控制原发病灶的方法。方法 对40例肺癌伴恶性胸水者行手术、免疫、介入或化疗。结果 所有病人胸水消失,29例死于术后6－31个月（平均13个月）,9例术后5－52个月仍生存。结论 外科综合治疗肺癌伴恶性胸水效果显著。     

Two cases of thymic carcinoma effectively treated by preoperative chemotherapy

A 67-year-old man was admitted with left pleural effusion on chest X-ray film. Chest CT scans showed an anterior mediastinal tumor, left pleural dissemination and pleural effusion. Percutaneous needle biopsy yielded a diagnosis of epitherial carcinoma. The patient underwent 3 courses of systemic chemotherapy (CDDP + ADM + VCR + CPA). At achievement of partial response, the tumor was completely resected. Examination of the resected tumor revealed partial response to chemotherapy. A 49-year-old woman was admitted our hospital with supraclavicular lymph nodes swelling. Chest CT scans showed an large mediastinal tumor. Percutaneous needle biopsy yielded a diagnosis of squamous cell carcinoma of thymus. The patient underwent 3 courses of systemic chemotherapy. At achievement of partial response, the tumor was completely resected. Examination of the resected tumor revealed partial response to chemotherapy. These cases indicate the usefulness of preoperative chemotherapy for advanced thymic carcinoma to reduce tumor size and to control local invasion, distant metastasis before operation.     

Palliative treatment of malignant pleural effusions by video-assisted thoracoscopic surgery

Malignant pleural effusion (MPE) are associated with significant morbidity. Prompt clinical evaluation followed by aggressive treatment often results in successful palliation. Video-assisted Thoracic Surgery (VATS) today can be employed in the diagnosis and treatment of idiopatic and known MPE. Between January 1994 and December 1998 233 MPE patients were treated with pleurodesis. 206 of them underwent tube thoracostomy and drainage alone followed by chemical pleurodesis. In 27 out of the 233 cases VATS management was applied. These patients had undiagnosed pleural effusions or recurrent MPE following failed previous drainage and pleurodesis. The cause of the effusion was breast cancer in 11 patients, lung cancer in 9, urogenital cancer in 3, mesothelioma in 2 and other in 2. VATS intervention was thoracoscopic exploration with biopsy and directed chemical sclerosis in undiagnosed MPE (19/27) and lysis of pleural adhesions with partial decortication and pleurodesis in recurrent effusions (8/27). VATS managements were successful 26/27 after mean follow up of 6 months. Had not mortality postoperatively and severe morbidity. Chest tubes were removed 1.5 +/- 0.5 days postoperatively and hospital stay were averaged 4 +/- 1 days. We concluded that VATS is a safety and effective way of managing selected patients with pleural effusions.     

A case of giant dumbbell shaped schwannoma with massive pleural effusion

A 58-year-old female was admitted to the hospital complaining of dyspnea. The chest roentgenogram and CT scan revealed a large mediastinum tumor and massive pleural effusion in the right hemithorax. The diagnosis of lung cancer with carcinomatous pleulitis was performed through thoracocentesis an treatment of chemotherapy was chosen. After 6 years, she was admitted again to the hospital complaining of dull pain in the right leg. Chest CT scan and MRI showed a giant dumbbell shaped mass connected to the spinal canal. The tumor was larger than that of six years ago and diagnosed as schwannoma by CT-guided pericutaneous needle biopsy. At operation, hemilaminectomy of Th 1-3 was done first, and total tumor resection was performed through posterolateral thoracotomy. Intrathoracic adhesion was severe and it was difficult to control air leakage from the lung, thoracoplasty was performed.     

Pathological Diagnosis and Cytoreduction of Cardiophrenic Lymph Node and Pleural Metastasis in Ovarian Cancer Patients Using Video-Assisted Thoracic Surgery

Background  The aim of this study was to assess the benefit of video-assisted thoracic surgery (VATS) in pathological diagnosis and intrathoracic cytoreduction of cardiophrenic lymph node (CPLN) and pleural metastasis on computed tomography (CT) in patients with ovarian cancer. Methods  We reviewed a database of ovarian cancer patients who underwent VATS from June 2007 to November 2008. The criterion for suspicion of malignancy on CT was either a CPLN with short-axis dimension >5 mm or multinodular pleural thickening. Seven patients with primary ovarian cancer and five patients with recurrent ovarian cancer were identified and evaluated. Results  Twelve patients met the criterion for suspicious malignancy on CT, with CPLN metastasis and pleural metastasis in nine and five patients, respectively. CPLN metastasis was identified in two of four patients with primary ovarian cancer and in all five patients with recurrent ovarian cancer who had CPLN >5 mm on CT. Pleural metastasis was identified in three of five patients with suspicious pleural metastasis and in one of seven patients without suspicious pleural metastasis on preoperative CT. The median operation time for VATS was 65 min and estimated blood loss was less than 20 ml in all cases. All visible intrathoracic diseases were completely resected without major complications, and VATS did not delay planned treatment. Conclusion  VATS enables the accurate pathological diagnosis and intrathoracic resection of pleural and CPLN metastasis in patients with ovarian cancer with acceptable morbidity. Further studies are needed to confirm the impact of VATS on survival in patients with ovarian cancer.     

Pseudomesotheliomatous carcinoma of the lung

Pseudomesotheliomatous carcinoma is the lung cancer with marked pleural extension resembling malignant pleural mesothelioma on diagnostic imaging. We report a rare case of pseudomesotheliomatous carcinoma of the lung in a 72-year-old man. The patient had complained of dyspnea and a chest roentgenogram showed right pleural effusion. Computed tomography (CT) of the chest revealed diffuse irregular pleural thickening, which mimicked pleural malignant mesothelioma. Pleural tissue sampling was performed to obtain definitive diagnosis by video-assisted thoracoscopic surgery. At the operation. the tumor was found to have a spread along the pleural surface and primary lesion was not detected in the right lung parenchyma. Immunohistochemically, the tumor was positive for carcinoembryonic antigen (CEA), but negative for calretinin, thrombomodulin, and pulmonary surfactant apoprotein. Final diagnosis was adenocarcinoma of the lung.     

An extrapleural approach to the anterior mediastinum using video-assisted thoracic surgery (VATS)

A lateral extrapleural approach via video-assisted thoracic surgery (VATS) was used in a patient suspected of having a benign tumor of right lobe of the thymus. The patient previously had undergone lung resection for pulmonary tuberculosis, and the ipsilateral thorax had contracted and dense pleural adhesions were likely to exist. Lateral extrapleural approach by VATS was performed successfully and is an alternative to open surgery in highly selected patients with anterior mediastinal lesions.     

Mycobacterium avium complex (MAC) infection needed differential diagnosis of the recurrence after surgery for double lung cancer; report of a case

A 62-year-old woman had undergone video-assisted thoracic surgery (VATS) -right upper lobectomy and right S8 segmentectomy for double lung cancers (papillary adenocarcinoma and bronchioloalveoler carcinoma, stage IA). Four years later, chest computed tomography (CT) showed abnormal shadow, 20 mm in size, along the staple-suture line. The 3 months later, new lesion, 15 mm in size, was observed in right lower lobe. CT-guided biopsy revealed no malignancy. The patient underwent partial resection of the right lower lobe and tumorectomy. The tumor was solid and cystic mass. Histopathologically, the tumor was granuloma infected by Mycobacterium avium. The patient was discharged on 17th postoperative day, and doing well without new lesion for 9 months postoperatively.     

Metastatic granulosa cell tumour of the diaphragm 15 years after the primary neoplasm.

We present the case of a female patient who complained of dyspnoea and was found to have a pleural effusion. A tumour involving the right diaphragm was seen on CT and after excision this was shown to be a recurrent granulosa cell tumour, 15 years after the original ovarian lesion had been treated by oophrectomy and radiotherapy. The case and literature relating to such a rare intra-thoracic metastatic tumour is discussed.     

Human pulmonary dirofilariasis in a patient whose clinical condition altered during follow-up

Pulmonary dirofilariasis is a rare disease. We have experienced a case which developed pleural effusion while being followed, rendering it difficult to establish the diagnosis. The patient, a 53-year-old woman, had previously undergone two operations; one for uterine cancer and another for breast cancer. She developed a cough in February 2002, and chest computed tomography (CT) scans disclosed a nodular mass in the right lung. A biopsy revealed a fibrous nodule with macrophage aggregation. Pleural effusion was demonstrated on chest CT scans performed in May. As the possibility of malignant tumor could not be ruled out, an operation was undertaken. The nodular lesion showed marked coagulation necrosis, and dead parasites were noted in the vascular lumen. The parasites had the characteristic morphological features of Dirofilaria immitis. Immunological studies produced a positive test result for the anti-dirofilaria immitis antibody; hence a diagnosis of pulmonary dirofilariasis was made.     

Renal cell carcinoma with malignant pleural mesothelioma after asbestos exposure: a case report

A 66-year-old man visited complaining of cough and sore throat. He had been exposed to asbestos 43 years ago. Chest X-ray revealed left pleural effusion and abnormal shadow in the right lung field. Chest computed tomography (CT) showed multiple enhanced nodules in the right pleural cavity. Abdominal CT showed a 3-cm enhanced tumor in the lower pole of the left kidney. Left radical nephrectomy was performed. Pathological diagnosis was renal cell carcinoma. Postoperatively pleural biopsy was performed by using thoracoscopy. White plaque was seen at the costal pleura and surface of lung. Pathological diagnosis was malignant pleural mesothelioma based on using mesothelium-associated antibodies: calretinin (+), CK5/6 (+), D2-40 (+), HBME-1 (+), TTF-1 (-), MOC31 (-), CEA (-). Combination therapy (extrapleural pneumonectomy, chemotherapy, and radiotherapy) was initiated. Malignant mesothelioma is a devastating neoplasm with a strong etiological relationship with asbestos exposure. The incidence is rising in industrialized countries, with the peak expected in the year 2020. However, renal cell carcinoma with malignant pleural mesothelioma is very rare and this is the 2nd case in the Japanese literature.     

胸膜间皮瘤的诊断与治疗

经手术病理证实的胸膜间皮瘤１８例，其中良好性１５例，恶性１３例，局限型７例，弥漫型１１例。本病术前误诊率高，本组误诊８例。１９例均行手术治疗，术后３例失访。本病诊断主要依靠胸水的检查和胸膜活检；局限型胸膜间皮瘤一经确诊，主张早期手术；弥漫型确诊后如患者全身情况允许，应行广泛手术切除及术后综合治疗，以利于延长患者生命。     

Thoracoscopic talc pleurodesis for recurrent, symptomatic pleural effusion following cardiac operations

Seventeen patients who underwent a cardiac operation developed a recurrent, symptomatic pleural effusion ultimately requiring video-assisted thoracic surgery (VATS) and talc pleurodesis. These patients represented 0.4% of all patients undergoing a cardiac operation over the same time period. Compared with an age- and sex-matched control group of cardiac surgery patients, patients requiring VATS for recurrent pleural effusion were more obese with higher body mass index (31.9 +/- 1.2 versus 28.3 +/- 1.4 kg/M2, P = 0.03), were more likely to have undergone a complex cardiac operation (8/17 versus 1/17, P =.01) and were more frequently on anticoagulation and antiplatelet agents besides aspirin (8/17 versus 2/17, P =.02). Patients underwent 1.86 +/- 0.34 thoracenteses with drainage of 846 +/- 166 mL/thoracentesis prior to referral for VATS. On average, patients underwent VATS 4.83 +/- 1.49 months after their cardiac operation. There were 3 VATS-related complications (17.6%) and no deaths. VATS talc pleurodesis led to symptomatic and radiologic improvement in all patients with a mean follow-up of 8.2 +/- 1.5 months. VATS talc pleurodesis effectively and safely treats the unusual postcardiac surgery patient with refractory pleural effusion.     

Usefulness of thoracoscopic surgery in the diagnosis and management of thoracic diseases

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) has been recently utilised in the diagnosis and management of thoracic diseases. In this article we report our series of patients with established indications for VATS treatment. METHODS: Over the past 6 years we performed 104 VATS procedures for diagnostic and therapeutic purposes in 95 men and 39 women. The specific indications for VATS were: lung biopsy for undiagnosed diffuse lung disease, mediastinal biopsy and cysts, pleural effusion, empyema, pneumothorax and bullous lung disease, pericardial effusion and cyst, parvertebral abscess and solitary pulmonary nodules. RESULTS: There was no operative mortality. Postoperative non-fatal complications were seen in 7 cases. The overall median duration of chest tube drainage was 2.5 days and the mean postoperative stay 3 days. In diffuse lung disease a tissue diagnosis was obtained in all cases. Definitive diagnosis in the patients with undiagnosed pleural effusion was obtained in 90% of cases and the overall diagnostic rate was 98.5%. The success rate of the empyema (stage II) treatment and the therapeutic procedures is 100% after a mean follow-up of 12 months (range 6-30). Conversion to thoracotomy was needed in 6 cases. In all patients the postoperative pain was controlled with intake of non-narcotic analgesics with satisfactory results. CONCLUSIONS: VATS is worth considering and has been established as procedure of choice, with exceptional results in various chest diseases such as undiagnosed pleural effusions, recurrent, post-traumatic or complicated spontaneous pneumothorax, stage II empyema, accurate staging for lung cancer in the resection of peripheral solitary pulmonary nodule less than 3 cm, and lung biopsy for pulmonary diffuse disease.     

电视胸腔镜诊治胸腔积液的临床体会

目的:探讨电视胸腔镜手术诊治胸腔积液的应用价值。方法:回顾分析2006年3月至2012年8月为152例胸腔积液患者行电视胸腔镜手术的临床资料。双腔气管插管全麻后置入胸腔镜及活检钳,取胸膜组织送病理检查,并根据病理检查结果决定治疗方案。结果:152例患者中肺癌胸膜转移83例,恶性胸膜间皮瘤18例,胸腺瘤3例,恶性肿瘤胸膜转移16例,来源不明的转移肿瘤4例,结核性胸水25例,3例未明确诊断。恶性胸腔积液患者行滑石粉胸膜固定,根据病理类型术后予以规范化抗肿瘤治疗。结核性胸腔积液患者,术后予以正规抗结核治疗。余者均根据病理回报结果进行相应后续治疗。结论:电视胸腔镜手术诊治胸腔积液微创,确诊率高,疗效确切,为进一步治疗疾病提供了有力证据。     

Long-term follow-up of video-assisted talc pleurodesis in malignant recurrent pleural effusions.

OBJECTIVE: Recurrent pleural effusion is a common condition and often presents a challenge for treatment. The aim of this report is to evaluate the long-term follow-up of thoracoscopic management of malignant recurrent pleural effusions. METHODS: From July 1st, 1992 to February 28th, 2001, out of 2311 VATS procedures performed at our Institution, 690 patients (29.85%) underwent videothoracoscopy (VATS) for recurrent pleural effusion. Of these 611 (88.55%) were treated for a malignant pleural effusion. There were 374 male and 237 female, with a mean age of 61.2 years. In all patients VATS was performed under general anaesthesia. The pleural effusion was carefully aspirated; fibrinous adhesions were taken down while dense fibrous adhesions were selectively divided; some limited decortications were also performed. Multiple pleural biopsies were always performed. Pleurodesis was performed with 5 g of sterile purified talc insufflated through a talc atomizer. One chest tube was left in situ for 3-5 days. RESULTS: Operative mortality was 0.81% (five cases). Postoperative complications occurred in 19 cases (3.1%). Specific histologic diagnosis was obtained in all patients. Follow-up was available for 602 patients (98.5%). After a median follow-up of 64 months (range 5-105 months), talc pleurodesis was successful in controlling recurrence of effusion in 92.7% (558 out of 602) of patients. The success rate did not show any statistically significant difference between patients who underwent postoperative adjuvant therapy and patients who did not. In two patients with failure of talc pleurodesis a redo-VATS was performed. CONCLUSIONS: VATS represents the method of choice for both diagnosis and treatment of malignant recurrent pleural effusions. Talc poudrage is safe and effective in obtaining pleurodesis.     

Intractable pneumothorax for pleuritis carcinomatosis effectively treated with bronchial embolization: report of a case

A 57-year-old female was admitted with compliant of cough and body weight loss. Chest X-ray and thoracic computed tomography (CT) scan revealed a collapsed lung and pleural effusion. We diagnosed a pleulitis carcinomatosis. After right chest tube drainage was performed, she developed right intractable pneumothorax. It was occluded endobronchially by the placement of vascular embolization coils and histoacryl. This method is thought to be an effective treatment for intractable pneumothorax patients in endstage of lung cancer.