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A patient with pleuroparenchymal fibroelastosis (PPFE) was successfully treated with living-donor lobar lung transplantation. A 27-year-old woman with a 3-month history of dyspnea received a diagnosis of PPFE. Her chest wall was extremely flattened over time, and her respiratory condition progressively deteriorated. She underwent semielective bilateral living-donor lobar lung transplantation. Her chest wall rigidity, which was secondary to PPFE, required intensive pulmonary rehabilitation postoperatively. By 6 months after transplantation, the flattening of her chest wall was reversed. Living-donor lobar lung transplantation was a life-saving procedure for this patient and improved the chest wall deformity of PPFE., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

A patient receiving bilevel positive airway pressure therapy underwent radiofrequency ablation of a pulmonary metastasis from a primary malignant fibrous histiocytoma of the scapula. The patient's postablation course was complicated by a bronchopleural fistula, which was exacerbated by the detrimental effects of positive airway pressure on necrotic lung tissue after the ablation. The use of positive airway pressure devices, including bilevel positive airway pressure and continuous positive airway pressure, in patients undergoing radiofrequency ablation of the lung should be considered as an added risk for developing bronchopleural fistula., (Copyright (c) 2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Approximately 1% of patients with rheumatoid arthritis have chronic lung disease develop, which can lead to complications, including pneumothorax and bronchopleural fistula. Given the inflammatory changes found, along with the immunosuppressant regimen used in management, these complications are often recalcitrant to initial surgical maneuvers. Our goal in reviewing these patients is to demonstrate the escalation of therapeutic interventions that may be needed to ensure successful resolution of this challenging disease process.

Calcifying fibrous pseudotumor is an extremely rare benign lesion that develops in the pleura. We describe a case of multiple lesions in the pleura. The patient is a 52-year-old woman who had a subpleural mass on chest roentgenogram. The diagnosis was established by percutaneous needle biopsy. The largest tumor was hanging down from the parietal pleura, and additional small nodules were disseminated throughout the pleural cavity. Only a few tumors arising from the largest one were resected, and the others were left unresected. The resected tumors consisted of collagenous fibrous tissue, calcifications, and spindle cells that were positive only for vimentin immunostaining.

We describe a 65-year-old man who was treated for an empyema after a right middle and lower lobectomy for adenocarcinoma with a Clagett procedure who subsequently had a bronchopleural fistula develop. After adequate debridement of the cavity through dressing changes, the right bronchus intermedius bronchopleural fistula was closed using a collagen porcine plug (Surgisis anal fistula plug [Cook Medical Inc, Bloomington, IN]) placed through the cavity into the fistula along with the placement of omentum into the cavity. This case report illustrates the utility of collagen plugs to close bronchopleural fistulas.

Standard treatment for persistent bronchopleural fistulas involves thoracotomy with primary closure and transposition of a vascularized muscle flap to the bronchial leak site. This major operation may be ineffective or medically contraindicated. We successfully treated 2 patients by insertion of coils and cyanoacrylate glue into and adjacent to the fistula of a postpneumonectomy bronchial stump with computed tomographic-guided transthoracic needle. The coils served as scaffolding for cyanoacrylate glue to control the bronchopleural fistula.

Background: The presence of pleural adhesions may render video-assisted thoracoscopic surgery difficult or impossible. The aim of this study was to assess the value of chest ultrasonography in the detection of pleural adhesions prior to thoracotomy., Methods: Between October 2001 and September 2002, 42 consecutive patients undergoing thoracotomies (including video-assisted thoracic surgery) were evaluated with chest ultrasonography. These patients underwent a preoperative ultrasonic examination of the chest wall using a 7-MHz linear ultrasound probe at 7 points along the chest wall. We measured the movement of the visceral pleural slide., Results: When restricted viscera sliding was defined as less than 1 cm of excursion at the upper thoracic wall during exaggerated respirations, ultrasonography demonstrated a sensitivity of 63.6%, a specificity of 79.4%, a negative predictive value of 87.7%, a positive predictive value of 50.0%, and an overall accuracy of 75.6%. When restricted viscera sliding was defined as less than 2 cm of excursion at the lower thoracic wall during exaggerated respirations, ultrasonography demonstrated a sensitivity of 81.5%, a specificity of 81.0%, a negative predictive value of 96.0%, a positive predictive value of 44.0%, and an overall accuracy of 81.0%., Conclusions: Chest ultrasonography is moderately accurate in detecting the presence and location of pleural adhesions. Use of preoperative chest sonographic findings to plan trocar placement and to determine the need for an open approach is valuable in helping prevent visceral injury and facilitating video-assisted thoracoscopic surgery.

Calcifying fibrous pseudotumor is a rare lesion recently reported in the literature. We report a new case occurring in the pleura, which is an unusual location. The patient, a 38-year-old woman, had a left pleural mass revealed by chest roentgenograms. The tumor was resected by video-assisted thoracotomy. Only 26 cases have been reported in the literature to date, but only 4 cases have been reported in the pleura. The pathogenesis is discussed but remains uncertain. Tumor resection appears to be the best option and the clinical course is benign. However, the number of cases to date is insufficient to establish therapeutic recommendations.

Background: Traumatic subarachnoid-pleural fistula is a very uncommon but important condition. Only 21 cases have been reported so far in the world literature., Methods: We encountered 2 cases of subarachnoid-pleural fistula, both in pediatric patients presenting without any neurologic deficit. Whereas our first patient presented with recurrent, rapidly filling clear pleural effusions with an obscure cause, posing a diagnostic problem for the pediatricians, the second patient had trauma to the pleura and dura mater by the sharp edge of Kirschner wire, with impending risk of injury to spinal cord and infection., Results: Surgical intervention was undertaken after we had a strong suspicion of subarachnoid-pleural fistula in both cases. A subarachnoid-pleural fistula was found at the level of the eleventh thoracic vertebra in the first patient and at the level of the eighth thoracic vertebra in the second patient. Autogenous tissues (mediastinal pleural flap and hammered intercostal muscle covered with methylcellulose) were used to repair the fistula. The subarachnoid space was decompressed with a lumbar drain in the second patient., Conclusions: The diagnosis of subarachnoid-pleural fistula is difficult when it is not associated with any neurologic deficit. We found that a high degree of suspicion and early surgical intervention to repair the fistula are rewarding.

Occult bronchopleural fistulas are frequently present when empyemas develop in a postpneumonectomy space. Recognition of the bronchial stump disruption can be difficult, which may lead to delays or errors in the management of these difficult problems. We report the use of xenon ventilation nuclear scintigraphy as an effective noninvasive means of confirming the diagnosis of occult postpneumonectomy bronchopleural fistulas.

Over a 14-year period, we observed eight cases of esophagopleural fistula after pneumonectomy for cancer (n = 7) or infectious lung disease (n = 1). In 2 patients, the fistula was probably related to an intraoperative esophageal injury. Two others had mediastinal cancer recurrence, whereas a fistula developed in 4 without any malignancy. Patients presented with empyema, and a contrast swallow procedure disclosed an esophagopleural fistula. Two patients with recurrent cancer were managed conservatively with chest tube insertion and died within 3 months. A patient with chronic empyema had a delayed diagnosis of esophagopleural fistula 2 years after a presumed intraoperative injury; he was managed with thoracoplasty and feeding gastrostomy and died 12 months later. Five patients had an attempt at curative treatment. A single patient underwent thoracoplasty and bipolar exclusion of the esophagus and had secondary reconstruction with a coloplasty; he died with postoperative peritonitis. Four patients underwent thoracoplasty and muscle flap repair of the esophagus. There was 1 operative death from pulmonary embolism, whereas 3 patients recovered and are well with follow-up of 18 months, 2 years, and 5 years, respectively. We conclude that the prognosis of esophagopleural fistula is ominous when associated with cancer recurrence. A curative approach should combine direct repair of the esophagus with a muscle flap and eradication of the associated empyema with thoracoplasty. This aggressive treatment is addressed to debilitated patients and carries high rates of mortality and morbidity.

We report a case of successful closure of a postpneumonectomy bronchopleural fistula by means of the transpericardial approach with omentopexy through a median sternotomy incision. This method minimizes problems of infection, healing, and pulmonary function.

Among 1,577 persons with asbestos exposure followed up from 3 to 30 years, 113 had thoracic surgical procedures for asbestos-related disorders. Twenty-six individuals suspected of having asbestosis with atypical features underwent open-lung biopsy; a different disease was revealed in 14. Most of the 29 patients with mesothelioma had a small thoracotomy for diagnosis only; chemotherapy in half of them proved entirely ineffective. Experience with 23 patients with bronchogenic carcinoma did not differ from that in persons not exposed to asbestos. Problems of causal relationship are discussed. Most of the 68 individuals with benign asbestos pleural effusion had no symptoms, but because of recurrence, 15 were operated on for decortication or for possible mesothelioma. Hyaline plaques often were mistaken for lung, rib, or diaphragmatic tumors, and sometimes mesothelioma was suspected. Operative intervention in the 24 patients with plaques could have been avoided by obtaining a more detailed occupational history and reviewing previous chest roentgenograms, which invariably showed identical or smaller plaques from 2 to 17 years earlier.