Faculty Bibliography

This article has provided a detailed description of the entire decision-making process of chest tube management. Although these protocols were derived from prospective randomized trials, further studies are needed.

BACKGROUND: Air leaks prolong hospital stay. METHODS: A prospective algorithm was applied to patients. If patients were ready for discharge but still had an air leak, a Heimlich valve was placed and they were discharged. If the leak was still present after 2 weeks, the tube was clamped for a day and removed. RESULTS: There were 669 patients. Factors that predicted a persistent air leak were FEV1% of less than 79% (p = 0.006), history of steroid use (p = 0.002), male gender (p = 0.05), and having a lobectomy (p = 0.01). Types of air leaks on day 1 that eventually required a Heimlich valve were expiratory leaks (p = 0.02), leaks that were an expiratory 4 or more (p < 0.0001), and the presence of a pneumothorax concomitant with an air leak (p < 0.0001). Thirty-three patients were placed on a Heimlich valve, and 6 patients had a pneumothorax or subcutaneous emphysema develop; all patients had an expiratory 5 leak or larger (p < 0.0001). Thirty-three patients went home on a valve. Seventeen patients had leaks that resolved by 1 week, 6 by 2 weeks, and the remaining 9 had their tubes removed without problems. CONCLUSIONS: Steroid use, male gender, a large leak, a leak with a pneumothorax, and having a lobectomy are all risk factors for a persistent leak. Discharge on a Heimlich valve is safe and effective for patients with a persistent leak unless the leak is an expiratory 5 or more. Once home on a valve, most air leaks will seal in 2 weeks; if not, chest tubes can be safely removed regardless of the size of the leak or the presence of a pneumothorax.

Adenocarcinoma (AC), squamous cell carcinoma (SCC) and adenosquamous carcinoma (ASC) of the lung are morphologically distinguished in part by cyto-architectural features. However, little is known about the relative expression and distribution of cyto-architectural proteins among AC, SCC and ASC. Initial microarray analysis revealed significant differences in expression of two cyto-architectural genes in AC, SCC and ASC. Desmoplakin (DP) 1 and 2, which link desmosomes to intermediate filaments, was strongly expressed in SCC relative to AC and ASC. Cytokeratin 18 (CK18), an intermediate filament that is commonly linked to desmoplakin, was strongly expressed in AC and ASC relative to SCC. Western blot analysis demonstrated that AC and ASC had abundant CK18 protein, whereas CK18 was weakly detected in SCC. DP 1 and 2 are strongly expressed in SCC and minimally expressed in AC and ASC. However, the ratio of one to the other is the same in SCC and AC, but DP2 is lost in ASC. Microscopic analysis with fluorescence-labeled antibodies for CK18 and DP 1 and 2 revealed abundant membrane localization of DP and minimal perinuclear localization of CK18 in SCC. In contrast, in both AC and ASC, the CK18 protein was diffusely distributed within the cytoplasm, and DP showed both membranous and cytoplasmic localization. In conclusion, the data here shows that AC, SCC and ASC each have specific patterns of DP 1 and 2 and CK18 gene expression, protein content and biodistribution.

Small pleural effusions that cannot be assessed by thoracentesis prior to surgery may represent a diagnostic challenge in the patient with a resectable, non-small cell cancer of the lung. Even if the effusion is drained preoperatively and analyzed, the cytology may be falsely negative. We have found that careful inspection of pleural effusions using a single small 2-cm incision and video-assisted thorascopy may reveal a gelatinous piece of clotlike material that resembles a jellyfish. This cohesive particulate piece of material lies in the effusion. This material can be sent for frozen section (unlike cytologic exams in most hospitals), and an immediate answer can be obtained. Cytology results of the surrounding effusion that return 24 hours later confirm the frozen section findings. If malignant, this avoids thoracotomy and pulmonary resection in a patient with unsuspected T4, stage IIIB lung cancer. It also avoids closing a patient with an unsuspected effusion and having to wait 24 hours for the cytology results. We review our experience with this jellyfish-like material.