Faculty Bibliography

BACKGROUND: Surgeons treat air leaks differently. Our goal was to evaluate whether it is better to place chest tubes on suction or water seal for stopping air leaks after pulmonary surgery. A second goal was to evaluate a new classification system for air leaks that we developed. METHODS: Patients were prospectively randomized before surgery to receive suction or water seal to their chest tubes on postoperative day (POD) #2. Air leaks were described and quantified daily by a classification system and a leak meter. The air-leak meter scored leaks from 1 (least) to 7 (greatest). The group randomized to water seal stayed on water seal unless a pneumothorax developed. RESULTS: On POD #2, 33 of 140 patients had an air leak. Eighteen patients had been preoperatively randomized to water seal and 15 to suction. Air leaks resolved in 12 (67%) of the water seal patients by the morning of POD #3. All 6 patients whose air leak did not stop had a leak that was 4/7 or greater (p < 0.0001) on the leak meter. Of the 15 patients randomized to suction, only 1 patient's air leak (7%) resolved by the morning of POD #3. The randomization aspect of the trial was ended and statistical analysis showed water seal was superior (p = 0.001). The remaining 14 patients were then placed to water seal and by the morning of POD #4, 13 patients' leaks had stopped. Of the 32 total patients placed to seal, 7 (22%) developed a pneumothorax and 6 of these 7 patients had leaks that were 4/7 or greater (p = 0.001). CONCLUSIONS: Placing chest tubes on water seal seems superior to wall suction for stopping air leaks after pulmonary resection. However, water seal does not stop expiratory leaks that are 4/7 or greater. Pneumothorax may occur when chest tubes are placed on seal with leaks this large.

Bronchopleural fistula (BPF) is a life-threatening complication after pulmonary resection. The incidence varies from 4.5% to 20% after pneumonectomy and is only 0.5% after lobectomy. Certain patient characteristics increase this incidence. These include preoperative radiation to the chest, destroyed or infected lung from inflammatory disease, immunocompromised host, and insulin-dependent diabetes. Certain surgical techniques also increase the incidence. These include pneumonectomy, right-sided pneumonectomy, a long bronchial stump, residual cancer at the bronchial margin, devascularization of the bronchial stump, prolonged ventilation, or reintubation after resection and surgical inexperience. The best treatment of a BPF is prevention. Prevention centers around meticulous surgical technique and the liberal use of prophylactic, pedicled muscle flaps for the patient at increased risk. Survival of BPF depends on a high index of suspicion, early diagnosis, and aggressive surgical intervention.

Pryce's type I intralobar sequestration, in which a region of lung exhibits tracheobronchial continuity and aberrant systemic arterial supply, is most frequently asymptomatic and discovered incidentally. While hemoptysis may be a common presenting symptom, massive hemoptysis is rarely seen. We document a case of a 58-year-old man, previously asymptomatic, whose initial presentation was that of massive hemoptysis. The radiographic, intraoperative and pathologic findings in our patient confirm that his sequestration was of Pryce's type I. Ann Diagn Pathol 5:91-95, 2001.

BACKGROUND: Removal of the right middle and lower lobes often leaves a pleural space problem that can cause prolonged air leaks. METHODS: A single surgeon prospectively randomized 16 patients who underwent bilobectomy. Eight patients had 1200 mL of air injected under the right hemidiaphragm after bilobectomy and 8 did not. The air was injected through a small transdiaphragmatic opening made in the right hemidiaphragm at the time of pulmonary resection. RESULTS: The age of the patients, preoperative pulmonary function, preoperative comorbidities, indications for surgery, and final pathology were not significantly different between the two groups. On postoperative day #1, a pneumothorax was present in 1 patient (13%) in the pneumoperitoneum group (P group) and in 4 patients (50%) in the nonpneumoperitoneum group (N-P group). On postoperative day 1, an air leak was present in 1 patient (13%) in the P group and 5 patients (63%) in the N-P group (p < 0.001). By the third postoperative day, no patient in the P group had an air leak; however, a leak was present in 4 patients (50%) in the N-P group (p < 0.001). Median hospital stay in the P group was 4 days (range, 3 to 6 days), compared with 6 days (range, 4 to 8 days) in the N-P group (p < 0.001). Three patients in the N-P group were sent home with a Heimlich valve. There was no operative mortality and no complications from the pneumoperitoneum. CONCLUSIONS: We conclude that pneumoperitoneum after bilobectomy is safe and easy to do. It decreases the incidence of air leaks and of pneumothoraces and shortens hospital stay without increasing morbidity. We recommend pneumoperitoneum after bilobectomy at the time of thoracotomy, especially if there are residual small air leaks that cannot be sealed before chest closure.

BACKGROUND: Inflammatory pseudotumors of the lung are rare and often present a dilemma for the surgeon at time of operation. We reviewed our experience with patients who have this unusual pathology. METHODS: Between February 1946 and September 1993, 56,400 general thoracic surgical procedures were performed at the Mayo Clinic. Twenty-three patients (0.04%) had resection of an inflammatory pseudotumor of the lung. There were 12 women and 11 men. Median age was 47 years (range, 5 to 77 years). Six patients (26%) were less than 18 years old. All pathologic specimens were re-reviewed, and the diagnosis of inflammatory pseudotumor was confirmed. Eighteen patients (78%) were symptomatic which included cough in 12, weight loss in 4, fever in 4, and fatigue in 4. Four patients had prior incomplete resections performed elsewhere and underwent re-resection because of growth of residual pseudotumor. Wedge excision was performed in 7 patients, lobectomy in 6, pneumonectomy in 6, chest wall resection in 2, segmentectomy in 1, and bilobectomy in 1. Complete resection was accomplished in 18 patients (78%). Median tumor size was 4.0 cm (range, 1 to 15 cm). There were no operative deaths. Follow-up was complete in all patients and ranged from 3 to 27 years (median, 9 years). RESULTS: Overall 5-year survival was 91%. Nineteen patients are currently alive. Cause of death in the remaining 4 patients was unrelated to pseudotumor. The pseudotumor recurred in 3 of the 5 patients who had incomplete resection; 2 have had subsequent complete excision with no evidence of recurrence 8 and 9 years later. CONCLUSIONS: We conclude that inflammatory pseudotumors of the lung are rare. They often occur in children, can grow to a large size, and are often locally invasive, requiring significant pulmonary resection. Complete resection, when possible, is safe and leads to excellent survival. Pseudotumors, which recur, should be re-resected.

We present the transesophageal echocardiographic findings in two adult patients with right-sided aortic arch: one without dissection and the other with traumatic aortic injury (dissection). In both patients, the branching pattern was the left common carotid artery and then the right common carotid artery, followed by the right and left subclavian arteries. The technique for the diagnosis of this anomaly and the identification of adjacent vascular structures using contrast echocardiography is described. Three-dimensional reconstruction of the aortic arch also was performed in both patients.