Modern Morbidity following Pulmonary Resection for Postprimary Tuberculosis

n = 8), multidrug resistance or noncompliance to the medical treatment ( n = 11), parenchymal sequelae ( n = 3), suspected cancer ( n = 5), and for the correction of postpneumonectomy bronchopleural fistula and empyema ( n = 1). On admission, eight patients presented with sputum positivity (28.6%). Similar to previous series, tubercular predilection for upper lobes was confirmed (21/28, 75%); accordingly, upper lobectomy through an extrapleural approach was the most common procedure (16/28, 57.1%). Atypical segmental resections or segmentectomies were performed in seven patients (25%), whereas a bilobectomy was necessary in another three patients (10.7%) and a completion pneumonectomy in one (3.6%). Additional procedures were an open-window thoracostomy with transpericardial closure of the main bronchus and a tailored thoracoplasty. No operative mortality was reported. Healing was achieved in 26 patients (93%). Bleeding, either from the chest wall or hilar dissection, was the only reported intraoperative complication. Median blood loss, inclusive of early postoperative collections from chest tubes, reached 1330 ml (range 100–3700 ml). Major postoperative complications included recurrent disease (2/28, 7%) in sputum-positive patients and segmental pulmonary embolism (3.5%). Causes of minor morbidity were air leaks resulting in residual space undergoing spontaneous resolution (18%), wound breakdown (14%), and, fever (11%). This limited series confirms the therapeutic value of the surgical treatment of postprimary tuberculosis, provided that correct indications, adequate pre- and postoperative medical coverage, and meticulous technique are applied.     

Pulmonary resection for lung cancer in HIV-positive patients with low (<200 lymphocytes/mm(3)) CD4(+) count

The clinical improvement obtained with combination treatment has modified the therapeutic approach of lung cancer in HIV-positive patients. Aggressive surgical treatment has become a viable option for those patients in whom the CD4(+) cell count was greater than 200 lymphocytes/mm(3). We recently extended our surgical indications to include two HIV-positive patients with lung cancer (stage IIIA and IIB) and low (<200 lymphocytes/mm(3)) CD4(+) count. Both patients underwent a lobectomy and mediastinal nodal dissection. The postoperative course was uneventful. No evidence of recurrent cancer was seen at 12 and 20 months after the operation. Based on this limited experience, we conclude that a low CD4(+) count should not represent, per se, an exclusion criterion for the surgical treatment of pleuropulmonary conditions in HIV-positive patients.     

Effectiveness of Leukocyte Filters in Reducing Tumor Cell Contamination after Intraoperative Blood Salvage in Lung Cancer Patients

Objectives: In an effort to reduce allogeneic blood transfusions in patients undergoing elective surgery for lung cancer, we investigated the effectiveness of a method of processing shed blood with an automated device for intra operative blood salvage (IOBS) and filtration with a 3rd-generation polyester filter to remove tumor cells. Methods: Sixteen patients were operated on for different types of lung cancer. We searched for malignant cells in pre- and postprocessed shed blood employing density gradient centrifugation, staining of cytospins with hematoxylin-eosin, and antibodies to human cytokeratins. Results: In 9 out of 16 cases (56%), neoplastic cells were detected in prefiltration samples, but none were found in postfiltration cytospins. Conclusion: IOBS combined with appropriate filtration could be a very useful and safe tool in reducing allogeneic blood transfusion in cancer patients.     

Pulmonary aspergilloma: clinical aspects and surgical treatment outcome

Aspergillomas are fungal balls within lung cavities. The natural history is variable. Hemoptysis is a dangerous sequela. Medical therapy is ineffective because of the lack of a lesion blood supply. Randomized trials are lacking. Surgery should be the treatment of choice in cases of hemoptysis, and even in asymptomatic patients, if lung function is not severely compromised. Cavernostomy and cavernoplasty may be options for high-risk patients. Percutaneous therapy should be reserved for patients who are not fit for surgery. Bronchial artery embolization is appropriate for symptomatic patients not suitable for surgery. Embolization could be considered a preoperative and temporary strategy.     

Impact of autologous blood transfusion on blood support in general thoracic surgery: analysis of 969 patients over a 5-year period

Autologous blood transfusion (ABT) is increasingly used in order to avoid transfusion-related risks. The effectiveness of this simple and feasible procedure depends on several factors, such as the timing of surgery, the patient's overall condition and, last but not least, the pre-disposition of the medical team towards the routine use of ABT. We report our experience in blood support with ABT for general thoracic surgical patients, indicating an overall partially satisfactory outcome due to a limited use of the procedure. In 1992, 61 patients (38%) received autologous blood only, as compared to 9 patients (6%) who had received ABT in 1989. The average pre-deposit per patient ratio in 1992 was 1.2 units, which provided insufficient autologous blood support. In the same period, only 23 patients were subjected to acute normovolemic hemodilution (ANH). However, we noted a reduction of homologous transfusions from 2.9 +/- < 2.1 in 1989 to 2.0 +/- < 1.5 in 1992 (P < 0.01). In addition, we observed that a single pre-deposit was not enough to enhance erythropoiesis and to improve post-operative red blood cell rescue when performed in patients with Hb > 11 g%. Based on our data, we emphasize a more extensive move to ANH, along with pre-deposit, in order to avoid unnecessary homologous blood transfusions.