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We report herein a case of thoracic infection due to Nocardia nova following lung re-transplantation performed for emphysema related to alpha-1-antitrypsin deficiency. The infection extended from the lung into the pleural space, thoracic wall, and mediastinum, presenting as pericarditis and empyema necessitatis. Nocardia nova was identified by 16S ribosomal deoxyribonucleic acid (rDNA) sequencing and phylogenetic analysis. According to a literature search of PubMed, LILACS and MEDLINE databases, we describe herein the first case of empyema necessitatis caused by N. nova species in a transplanted patient.

Objective: To investigate the impact of a pulmonary rehabilitation program on the functional capacity and on the quality of life of patients on waiting lists for lung transplantation., Methods: Patients on lung transplant waiting lists were referred to a pulmonary rehabilitation program consisting of 36 sessions. Before and after the program, participating patients were evaluated with the six-minute walk test and the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36). The pulmonary rehabilitation program involved muscle strengthening exercises, aerobic training, clinical evaluation, psychiatric evaluation, nutritional counseling, social assistance, and educational lectures., Results: Of the 112 patients initially referred to the program, 58 completed it. The mean age of the participants was 46 ± 14 years, and females accounted for 52%. Of those 58 patients, 37 (47%) had pulmonary fibrosis, 13 (22%) had pulmonary emphysema, and 18 (31%) had other types of advanced lung disease. The six-minute walk distance was significantly greater after the program than before (439 ± 114 m vs. 367 ± 136 m, p = 0.001), the mean increase being 72 m. There were significant point increases in the scores on the following SF-36 domains: physical functioning, up 22 (p = 0.001), role-physical, up 10 (p = 0.045); vitality, up 10 (p < 0.001); social functioning, up 15 (p = 0.001); and mental health, up 8 (p = 0.001)., Conclusions: Pulmonary rehabilitation had a positive impact on exercise capacity and quality of life in patients on lung transplant waiting lists.

Objective: To determine the main congenital lung malformations treated and the principal diagnostic methods employed, as well as the indications for surgical treatment and the results obtained, at a referral facility for pediatric thoracic surgery., Methods: We reviewed the medical charts of 52 patients anatomopathologically diagnosed with congenital lung malformations and who had been submitted to pulmonary resection between January of 1997 and December of 2006. Exclusion criteria were age > 12 years and incomplete clinical data. The final sample comprised 35 patients., Results: In this sample, the mean age was 31 months, and there was a predominance of males (n = 21). The anatomopathological findings were cystic adenomatoid malformation (n = 14), congenital lobar emphysema (n = 13), pulmonary sequestration (n = 8) and arteriovenous malformation (n = 1). The most common type of lung resection was left lower lobectomy (in 25.71%) followed by different types of segmentectomy (in 22.85%), left upper lobectomy (in 22.85%), right upper lobectomy (in 14.28%), right lower lobectomy (in 8.57%) and middle lobectomy (in 5.71%). Of the 35 patients, 34 (97.14%) were submitted to closed pleural drainage, with a mean duration of thoracic drainage of 3.9 days. Ten patients (28.5%) presented with postoperative complications. There were no deaths in our sample., Conclusions: Pulmonary resection for the treatment of congenital lung malformations is a safe procedure, presenting low morbidity and no mortality at a referral facility for pediatric thoracic surgery.

We present the case of a 54-year-old patient who presented to our institution 4 months after refusing surgical treatment for a right upper lobe cavitary carcinoma. Weight loss, hemoptysis, and worsening pulsatile chest pain were the complaints. Radiologic restaging surprisingly revealed a large pulmonary artery pseudoaneurysm occupying the whole cavity area. A right pneumonectomy with intrapericardial pulmonary artery ligation was performed. Previous cases are extremely rare and differ from ours as patients presented with advanced lung cancer and thus, were not treated with resection, but with coil embolization.

Post-intubation tracheal injury is a rare and potentially fatal complication. Among the most common causes, cuff overinflation and repetitive attempts of orotracheal intubation in emergency situations are paramount. Diagnosis is based on clinical and radiological suspicion, confirmed by fiberoptic bronchoscopy. Both conservative and surgical management apply, and the decision-making process depends on the patient profile (comorbidities, respiratory stability), characteristics of the lesion (size and location) and the time elapsed between the occurrence of the injury and the diagnosis. We report the cases of three patients presenting tracheal laceration due to traumatic orotracheal intubation, two submitted to surgical treatment and one submitted to conservative treatment.

A 59 years old female patient, asymptomatic, with the incidental finding of an ovarian tumor in her routine gynecological evaluation, and during the preoperative examinations it was incidentally found an isolated mediastinal tumor, and then routed to diagnostic evaluation of the lesion, which later proved to be a cystic lymphangioma. The cystic hygroma of the mediastinum is a benign tumor and very infrequent, representing only 0.7 to 4.5% of all mediastinal tumors, and of these, only 1% is exclusively mediastinal in location. The definitive diagnosis is only possible by pathological examination, and the recommended treatment consists of complete surgical resection. Cases are described in isolated reports or series with few patients, and their readiness or synchronicity with other tumors, unknown, and to the best of out knowledge, not reported yet.

The synchronous presentation of pulmonary and hepatic nodules in a patient with previously resected bronchogenic carcinoma raises suspicion of recurrence and mandates restaging. We present the case of a 71-year-old male with a history of lobectomy with pericardial resection and mediastinal lymphadenectomy (T3N0M0). At five years after the operation, he presented with a new pulmonary lesion. Restaging detected a synchronous nodule in the liver. Despite the strong suspicion of tumor recurrence, further investigation with a percutaneous liver biopsy revealed hepatocellular carcinoma. In order to investigate the etiology of the pulmonary lesion (hypotheses of recurrent bronchial cancer and of metastatic hepatocellular carcinoma), an open lung biopsy was performed, which revealed chronic inflammatory tissue with foci of anthracosis and dystrophic calcification. The patient was submitted to a non-anatomic resection of the liver lesion. The postoperative course was uneventful, and the patient was discharged on postoperative day 10. This report highlights the relevance of the histopathological diagnosis in patients with a history of bronchogenic carcinoma and suspicion of tumor recurrence. Differential diagnoses and the treatment administered are discussed.

Background: Many advances have substantially improved the clinical results of lung transplantation. However, the incidence of bronchial complications is still high, with significant impact on survival and limited interventional strategies for complex cases. Our aim is to evaluate the surgical management of bronchial complications following lung transplantation., Methods: From May 1989 to June 2007, 251 patients were submitted to lung transplantation at our institution. In five cases, the bronchial complications observed were dealt with open surgical procedures., Results: Complications surgically dealt were one broncho-arterial fistula and four stenosis. One left upper sleeve lobectomy, one right upper sleeve lobectomy and three segmental bronchial resections with anastomosis were performed. In all five cases the surgical procedure was successful and optimal bronchial healing was observed. Three patients died due to causes unrelated to the bronchial anastomosis 5, 21 and 32 months after the bronchoplastic procedure. Two patients are still alive and functionally well at 52 and 70 months post-bronchoplasty., Conclusions: Surgical management of bronchial complications after lung transplantation may be the last resort in complex, recalcitrant cases, nevertheless it is a feasible procedure and can provide good results not only on short- but also long-term follow-up.

Objective: To assess the esophageal function profile and the prevalence of gastro-esophageal reflux (GER) in lung transplant candidates., Methods: From July of 2005 to November of 2006, a prospective study was conducted involving 55 candidates for lung transplantation at the Santa Casa de Misericórdia Hospital in Porto Alegre, Brazil. Prior to transplantation, patients underwent outpatient stationary esophageal manometry and 24-h esophageal pH-metry using one and two electrodes., Results: Abnormal esophageal manometry was documented in 80% of the patients, and 24% of the patients presented pathological acid reflux. Digestive symptoms presented sensitivity and specificity for GER of 50% and 61%, respectively. Of the patients with chronic obstructive pulmonary disease, 94% presented abnormal esophageal manometry, and 80% presented lower esophageal sphincter hypotonia, making it the most common finding. Patients with bronchiectasis presented the highest prevalence of GER (50%)., Conclusions: In patients with advanced lung disease, GER is highly prevalent. In the population studied, digestive symptoms of GER were not predictive of pathological acid reflux. The role that GER plays in chronic rejection should be examined and clarified in future studies.

Objective: To objectively evaluate the reversal of digital clubbing (DC) in a series of surgically treated lung cancer patients, and to review the literature on the subject., Methods: Sixty-one patients with non-small cell lung cancer--40 with and 21 without DC--were treated by pulmonary resection. Eleven (18%) received additional postoperative radiation therapy. Preoperatively, as well as on postoperative days 7, 18, and 90, the hyponychial angle (HA) and the distal phalangeal depth/interphalangeal depth (DPD/IPD) ratio were determined on profile shadow projections of the index fingers. A review of the literature on reversal of DC (1954-2007) was also performed., Results: From the preoperative period to postoperative day 90, HA decreased from 200.5 +/- 5.0 masculine to 193.3 +/- 6.8 masculine (p < 0.001), and the DPD/IPD ratio decreased from 1.014 +/- 0.051 mm to 0.956 +/- 0.045 mm (p < 0.001) in the group of 40 patients with DC. The HA and the DPD/IPD ratio decreased in 33 (82.5%) but remained the same in 7 (1.7%), 6 with unfavorable evolution. In the 21 patients without DC, HA (184.5 +/- 5.5 masculine) and the DPD/IPD ratio (0.937 +/- 0.046 mm) remained unchanged after surgery. In the literature (1954-2007), we found 52 cases, 5 of which were lung cancer cases, in which reversal of DC, observed in several clinical conditions, was explicitly reported., Conclusion: In most lung cancer patients, DC resolves after effective surgical treatment of the tumor, as can occur in patients with other conditions.

Objective: To evaluate post-operative complications in living lobar lung transplant donors., Methods: Between September of 1999 and May of 2005, lobectomies were performed in 32 healthy lung transplant donors for 16 recipients. The medical charts of these donors were retrospectively analyzed in order to determine the incidence of postoperative complications and alterations in pulmonary function after lobectomy., Results: Twenty-two donors (68.75%) presented no complications. Among the 10 donors presenting complications, the most frequently observed complication was pleural effusion, which occurred in 5 donors (15.6% of the sample). Red blood cell transfusion was necessary in 3 donors (9.3%), and 2 donors underwent a second surgical procedure due to hemothorax. One donor presented pneumothorax after chest tube removal, and one developed respiratory infection. There were two intra-operative complications (6.25%): one donor required bronchoplasty of the middle lobe; and another required lingular resection. No intra-operative mortality was observed. Post-operative pulmonary function tests demonstrated an average reduction of 20% in forced expiratory volume in one second (p < 000.1) compared to pre-operative values., Conclusions: Lobectomy in living lung transplant donors presents high risk of post-operative complications and irreversible impairment of pulmonary function. Careful pre-operative evaluation is necessary in order to reduce the incidence of complications in living lobar lung transplant donors.

A case of invasive aspergillosis caused by Aspergillus niger in a lung transplant recipient is described. The patient presented hyperglycemia starting postoperatively, with other complications such as cytomegalovirus infection. The associated predisposing factors and other implications are discussed. Aspergillus niger seems to be a fungal species of low virulence that requires the presence of a severely immunosuppressed host to cause invasive disease.

The clinical practice of thoracic surgery requires the surgeon to have intimate knowledge of pulmonary anatomy and of its variations. Attempts to perform thoracic procedures without this knowledge can only result in incomplete operations or technical mishaps. Proper understanding of the anatomy of the pulmonary lobes, segments, and fissures allows the surgeon to correlate imaging, pathologic processes, and possible resectional procedures, thus insuring that each patient gets the best possible operation.

Objective: To analyze the impact that comorbidities have on the postoperative outcomes in patients submitted to lobectomy for the treatment of bronchial carcinoma., Methods: A retrospective study of 493 patients submitted to lobectomy for the treatment of bronchial carcinoma was conducted, and 305 of those patients met the criteria for inclusion in the final study sample. The surgical technique used was similar in all cases. The Torrington-Henderson scale and the Charlson scale were used to analyze comorbidities and to categorize patients into groups based on degree of risk for postoperative complications or death., Results: The postoperative (30-day) mortality rate was 2.9%, and the postoperative complications index was 44%. Prolonged air leakage was the most common complication (in 20.6%). The univariate analysis revealed that gender, age, smoking, neoadjuvant therapy and diabetes all had a significant impact on the incidence of complications. The factors found to be predictive of complications were body mass index (23.8 +/- 4.4), forced expiratory volume in one second (74.1 +/- 24%) and the ratio between forced expiratory volume in one second and forced vital capacity (0.65 +/- 0.1). The scales employed proved efficacious in the identification of the risk groups, as well as in drawing correlations with morbidity and mortality (p = 0.001 and p < 0.001). In the multivariate analysis, body mass index and the Charlson index were found to be the principal determinants of complications. In addition, prolonged air leakage was found to be the principal factor involved in mortality (p = 0.01)., Conclusion: Reductions in forced expiratory volume in one second, in the ratio between forced expiratory volume in one second and forced vital capacity, and in body mass index, as well as a Charlson score of 3 or 4 and a Torrington-Henderson score of 3, were associated with a greater number of postoperative complications in patients submitted to lobectomy for the treatment of bronchial carcinoma. Air leakage was found to be strongly associated with mortality.

Objective: To relate the experience of the staff at a health care facility specializing in the management of patients with aspiration lung abscess., Methods: Diagnostic aspects and therapeutic results of 252 consecutive cases of lung abscess seen in patients hospitalized between 1968 and 2004., Results: Of the 252 patients, 209 were male, and 43 were female. The mean age was 41.4 years, and 70.2% were alcoholic. Cough, expectoration, fever and overall poor health were seen over 97% of patients. Chest pain was reported by 64%, 30.2% presented digital clubbing, 82.5% had dental disease, 78.6% reported having lost consciousness at least once, and 67.5% presented foul smelling sputum. In 85.3% of the patients, the lung lesions were located either in the posterior segments of the upper lobe or in the superior segments of the lower lobe, and 96.8% were unilateral. Concomitant pleural empyema was seen in 24 (9.5%) of the patients. Mixed flora was identified in the bronchopulmonary or pleural secretions of 182 patients (72.2%). All patients were initially treated with antibiotics (mainly penicillin or clindamycin), and postural drainage was performed in 98.4% of cases. Surgical procedures were performed in 52 (20.6%) of the patients (drainage of empyema in 24, pulmonary resection in 22 and drainage of the abscess in 6). Cure was obtained in 242 patients (96.0%), and 10 (4.0%) died., Conclusion: Lung abscess occurred predominantly in male adults presenting dental disease and having a history of loss of consciousness (especially as a result of alcohol abuse). Most of the patients were treated clinically with antibiotics and postural drainage, although some surgical procedure was required in one-fifth of the study sample.

Pulmonary blastoma is a rare lung tumor that is composed of malignant epithelial and mesenchymal cells. It presents a pattern of rapid growth. Herein, we report the case of a patient with hemoptysis and a mass in the right upper lobe. The patient presented limited pulmonary function, and fiberoptic bronchoscopy revealed invasion of the intermediate bronchus. The patient underwent sleeve resection of right upper lobe, a technique never before described. After 36 months of follow-up, the patient remained asymptomatic. We also review the literature regarding treatment, clinical aspects and pathology.

Background: The purpose of this study was to evaluate canine lungs obtained from non-heart-beating donors after unilateral lung transplantation subjected to partial liquid ventilation with perfluorodecalin., Methods: Twelve donor dogs were killed and kept under mechanical ventilation for 3 hours. Heart-lung blocks were harvested after retrograde pulmonary hypothermic flush with Perfadex. Left lung grafts were randomly transplanted into 12 weight-matched recipient animals. Animals were divided into 2 groups: control (standard mechanical ventilation, n = 6) and PLV (partial liquid ventilation, n = 6). Forty-five minutes after transplantation, the animals in the PLV group received perfluorodecalin (15 ml/kg) via orotracheal tube. All animals received volume-controlled ventilation (FIO2) 1.0, PEEP 5 cm H(2)O) over 6 consecutive hours. Thereafter, blood-gas analysis, ventilatory mechanics and hemodynamics were registered at 30-minute intervals. After 6 hours of reperfusion the animals were killed and the transplanted lungs were extracted to obtain the wet/dry weight ratio., Results: There were significant differences in pulmonary arterial pressure, which were higher in control group animals (p < 0.009). The control animals also showed higher arterial PaO(2) than those in the PLV group (p < 0.00001), but lower PaCO(2) (p < 0.008). The peak and plateau pressures were higher in the PLV group (p < 0.00001). Neither static compliance nor wet/dry weight ratios were different in between groups., Conclusions: PLV with perfluorodecalin yields functional results compatible with life in this model. Nonetheless, pulmonary gas exchange and mechanics were superior after reperfusion in animals given conventional mechanical ventilation up to 6 hours after left lung allotransplantation.