Allergy and Airway

Chest. 2012;142(4_MeetingAbstracts):1A. doi:10.1378/chest.1387686

SESSION TYPE: Airway Cases I

PRESENTED ON: Monday, October 22, 2012 at 01:45 PM - 03:00 PM

INTRODUCTION: Benign endobronchial tumors are rare causes of post obstructive pneumonia and asthma.

CASE PRESENTATION: A 38 year-old woman of Middle Eastern origin with past medical history of mild intermittent asthma presented to the pulmonary service for evaluation of recurrent pneumonias for 3 years. Patient reported recent fever, chills, mild non-pleuritic chest pain, and cough productive of copious amount of purulent sputum mostly in the morning. These symptoms worsened gradually over 10 days despite outpatient antibiotic treatment for presumed pneumonia. She had at least 6 episodes in the previous 3 years with similar presentations that were treated successfully with oral and intravenous antibiotics. In the last 2 episodes she had mild self-limited hemoptysis. In three of the previous episodes she had right lower and middle lobes infiltrates. She reports that her symptoms as well as the frequency of infections are getting gradually worse. Her PPD skin test and quantiferon test were negative. Her pulmonary function test was unremarkable. The patient is a lifetime non-smoker, married housewife has three healthy children and no sick contacts and no previous significant occupational exposure. She reported history of tuberculosis in her father’s side. A CT-scan of the chest was obtained which revealed an endobronchial mass in the right bronchus intermedius (figure 1a), bronchoscopy confirmed an obstructing endobronchial mass in that location (figure 1b). A snare was utilized to remove mass and was accomplished successfully with complete opening of the airway and removal of a pedunculated mass (figure 2). Patient remained without any pneumonia for more than 4 months, and reports significant improvement in her cough, sputum production as well as her asthma symptoms.

DISCUSSION: Bengin endobronchial tumors account to 1-5 % of all endobronchial tumors (1, 3). Chondromas are a subset of these benign tumors that affect the bronchial tree. In one case series of endobrochial masses only 2 out of the 248 masses removed with sleeve resection were chondromas this case series malignant low grade tumors were included (2). Removal of this benign tumor has been reported using a laser resection but not with a simple snare technique as in our case. (3).

CONCLUSIONS: Chondromas are benign endobronchial tumors that can pose diagnostic and therapeutic challenge. Removal with interventional bronchoscopic techniques should be given a priority over surgery.

1) Grover et al; Endobronchial Chondroma: A Rare Tumor Causing Complete Left Mainstem Bronchial Occlusion. Chest; 2003; 262s.

2) Lucchi M, et al; Sleeve and wedge parenchyma-sparing bronchial resections in low-grade neoplasms of the bronchial airway. General thoracic surgery:2007 Aug; 134 (2):373-337.

3) Benign tumors of the tracheobronchial tree:endoscopic characteristics and role of laser resection.Chest 1995;107:1744-51.

DISCLOSURE: The following authors have nothing to disclose: Berhanemeskel Nesketa, Saadah Alrajab, Adam Wellikoff, Timothy Gilmore

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LSU-Shreveport, Bossier City, LA
Chest. 2012;142(4_MeetingAbstracts):2A. doi:10.1378/chest.1389245

SESSION TYPE: Airway Cases I

PRESENTED ON: Monday, October 22, 2012 at 01:45 PM - 03:00 PM

INTRODUCTION: Tracheal diverticulum is a rare typically benign condition characterized by invaginations of the tracheal wall resulting in paratracheal air cysts. We report a fairly symptomatic patient with such a condition.

CASE PRESENTATION: 50 year-old woman with a history of recurrent lung adenocarcinoma s/p right middle and lower lobectomy was hospitalized for worsening of dyspnea and foreign body sensation in her neck since surgery. She initially had a dry cough, but later developed hemoptysis. She was evaluated by indirect laryngoscopy and two bronchoscopies which were reportedly normal. Her vital signs were normal. She had inspiratory stridor over her neck and bilateral lung inspiratory and expiratory wheezing. PFT’s revealed flattening of expiratory flow volume loop and normal inspiratory limb consistent with variable intra-thoracic obstruction. A neck CT scan with 3- dimensional reconstruction revealed a circumscribed gas density structure adjacent to and apparently communicating with the right postero-lateral trachea consistent with tracheal diverticulum. She was treated medically with systemic antibiotics and discharged home. Unfortunately, she died a month later due to respiratory failure.

DISCUSSION: Although rarely reported in clinical practice, the incidence may be as high as 1-2%.(1) Tracheal diverticulum can be either congenital or acquired. Congenital tracheal diverticulum is typically smaller and located 4-5 cm below vocal cords. The acquired form may appear at any level, but commonly in the postero-lateral region. They may be due to increased intraluminal pressure caused by cough or COPD combined with a weakened trachea wall.(2) Most are asymptomatic and incidentally discovered on radiological imaging. It can retain secretions and manifest with chronic cough, recurrent respiratory infections, hemoptysis, stridor or rarely dyspnea. CT scan with 3-dimensional reconstructions are typically diagnostic. Diverticula with a narrow opening can be missed on bronchoscopy. Treatment options are typically conservative management although surgical intervention has been reported in symptomatic patients. (3)

CONCLUSIONS: The diagnosis of tracheal diverticulum is often challenging and delayed due to insidious clinical course and non-specific presentation. Therefore, clinicians should consider tracheal diverticulum in the differential diagnosis of patients with chronic respiratory symptoms.

1) D. Pinot, D. Breen. An incidental finding in a 34-year-old male with hemoptysis. Eur Respir J 2009; 33:1227-1229.

2) Soto-Hurtado EJ, Penuela L.Tracheal diverticulum: a review of the literature. Lung 2006;184(6): 303-307.

3) I. Kokkonouzis, D. Haramis. Tracheal diverticulum in an asymptomatic male. Cases journal 2008. I:181

DISCLOSURE: The following authors have nothing to disclose: Luis Chug, Sowjanya Duthuluru, Damien Stevens, Joel Mermis

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Kansas University Medical Center, Kansas City, KS
Chest. 2012;142(4_MeetingAbstracts):3A. doi:10.1378/chest.1383571

SESSION TYPE: Airway Cases I

PRESENTED ON: Monday, October 22, 2012 at 01:45 PM - 03:00 PM

INTRODUCTION: Bullous disease is a common feature of emphysema. Rarely, some patients undergo spontaneous resolution of bullae. We present a case of a patient who experienced significant physiological improvement after spontaneous auto-bullectomy.

CASE PRESENTATION: A 31-year-old male with 30 pack-years of smoking presented in 1980 with severe upper lobe bullous emphysema. Over the following 3-5 years he developed worsening exercise capacity requiring continuous home oxygen. His course was complicated by recurrent pneumothoraces and respiratory failure requiring tracheostomy. The patient continued to have very poor functional status and persistent giant bullae with limited expansion of adjacent lung parenchyma. Over the next 10 years he had a progressive decline in lung function. In 2000 the patient was hospitalized with bullitis. Imaging demonstrated unexplained right upper lobe atelectasis with mediastinal shift and a fluid-filled left apical bulla. He was treated with antibiotics, which led to resolution of the air-fluid level. Over the next 2 years, he experienced some improvement in exercise capacity. By 2003, imaging demonstrated near-complete resolution of the giant left bulla. Spirometry just 7 months later was markedly improved. The patient was lost to follow-up in 2004 but returned in 2012. He had significant and sustained improvement in his exercise capacity with mild residual symptoms. He no longer required supplemental oxygen.

DISCUSSION: Pulmonary bullae are air collections that are usually >2 cm in diameter. Giant bullae are typically defined as those that occupy >50% of the involved hemithorax. Potential complications include dyspnea, pneumothorax, and superinfection (bullitis). The treatment of choice for severe bullae is bullectomy (lung volume reduction surgery). Auto-bullectomy refers to spontaneous regression of bullae. The mechanism by which this occurs is not clear, but most processes suggest inflammation causing bronchiolar obstruction with consequent air resorption and bulla shrinkage. Our patient suffered many complications of giant bullae including pneumothoraces, respiratory failure, and bullitis. Surgical resection is employed to allow expansion of normal lung, improve gas exchange, and optimize diaphragm function. This patient achieved similar results without surgical intervention.

CONCLUSIONS: In summary, our patient suffered a profound decline in lung function with numerous complications before a spontaneous improvement in symptoms and physiology. This case demonstrates that auto-bullectomy in severe bullous emphysema can achieve results equivalent to lung volume reduction surgery.

1) Panchal NJ, et al. Bullous lung disease: a review. Cont Diag Rad. 2006; 29(1):1-5.

2) Orton DF, et al. Spontaneous reduction in size of bullae. J Thorac Imaging. 1999;14(2):118-21.

3) Scarlata S, et al. Spontaneous resolution of a giant pulmonary bulla in an older woman: role of functional assessment. Respiration. 2011;81(1):59-62.

DISCLOSURE: The following authors have nothing to disclose: Mir Alikhan, Eric Honig

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Emory University, Atlanta, GA
Chest. 2012;142(4_MeetingAbstracts):4A. doi:10.1378/chest.1388515

SESSION TYPE: Airway Cases I

PRESENTED ON: Monday, October 22, 2012 at 01:45 PM - 03:00 PM

INTRODUCTION: Anatomic airway anomalies should be considered in all children with persistent or recurrent wheezing which is unresponsive or poorly responsive to bronchodilators.

CASE PRESENTATION: Our patient has a history of chronic cough with wheezing since infancy with exacerbations triggered by both upper respiratory tract infections and exertion. Chart review showed recurrent episodes of wheezing on exam interspersed with normal chest exams. The working diagnosis was asthma. She came to our attention at age 12 years on a regimen of Serevent/Fluticasone 250/50, Montelukast and used Albuterol for rescue. On this regimen she still required multiple steroid bursts but because of variable compliance no further workup was done beyond an allergy evaluation which indicated seasonal nasal allergies. Chest radiographs were normal. Spirometry showed expiratory flow limitation and persistent flattening of the proximal portion of the flow-volume loop. During the subsequent 5 years her clinical course was essentially unchanged. At bronchoscopy the following images were taken: Image 1: complete tracheal rings; Image 2: tracheal bronchus Definitive Treatment: A slide tracheoplasty was performed. At five years post tracheoplasty follow up our patient is doing well with minimal exercise related symptoms.

DISCUSSION: Complete tracheal rings are rare and consist of absence of the posterior membranous portion of the trachea. Findings may be limited to a single segment of the trachea, multiple segments or may involve the entire trachea. Typical presentation occurs in the first year of life and is frequently associated with other malformations, particularly cardiac in origin. Symptoms may include dyspnea or stridor that is exacerbated with upper respiratory tract infections or physical exertion. Computerized tomography of the chest and bronchoscopy are used to define the extent of the lesion, identify other lesions and help to plan for definitive care. Tracheoplasty of stenotic segments is often helpful.

CONCLUSIONS: Our case is unusual because of the age at diagnosis,which more commonly occurs in the first few years of life.

1) Aneeshkumar MK., Ghosh S., Osman EZ., Complete tracheal rings: lower airway symptoms can delay diagnosis. Eur Arch Otorhinolaryngol. 2005 Feb: 264 (2): 161-162

2) Andrews TM, Cotton RT, Bailey WW, Myer CM 3rd, Vester SR, Tracheoplasty for congenital complete tracheal rings, Arch Otolaryngol Head Neck Surg. 1994 Dec; 120(12):1363-9

3) Gallagher TQ, Hartnick CJ., Slide tracheoplasty, Adv Otorhinolaryngol. 2012; 73: 58-62.

DISCLOSURE: The following authors have nothing to disclose: Giselle Barraza, Claudia Fernandez, Jon Roberts, Mary Cataletto

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Winthrop University Hospital, Mineola, NY
Topics: asthma , wheezing
Chest. 2012;142(4_MeetingAbstracts):5A. doi:10.1378/chest.1389213

SESSION TYPE: Airway Cases I

PRESENTED ON: Monday, October 22, 2012 at 01:45 PM - 03:00 PM

INTRODUCTION: Airway smooth muscle hypertrophy is a feature of obstructive lung disorders, including asthma and chronic obstructive pulmonary disease (1). We present a case of bronchial smooth muscle proliferation identified as part of a rare genetic disorder after a hospitalization for respiratory failure.

CASE PRESENTATION: A 55-year-old non-smoking female with a history of esophageal leiomyoma, s/p esophagogastrectomy, uterine leiomyoma, and vulvar leiomyomatosis presented to a local hospital with a two-day history of dyspnea. She declined rapidly requiring intubation and was transferred to our institution for further care. Computed tomography demonstrated no pulmonary embolus and unremarkable parenchyma (Figure 1). Echocardiogram revealed a pulmonary artery pressure of 49-mmHg with right ventricular dilatation. Sputum culture and viral studies returned negative. Laboratory testing was otherwise normal. The patient quickly improved without specific therapy and returned to our outpatient Pulmonary clinic for further investigation. The patient reported several episodes of bronchitis in childhood, with two prior hospitalizations for respiratory infections. She denied chronic cough and sputum production. She endorsed intermittent wheezing. Physical examination was unremarkable. Pulmonary function testing revealed a decreased FEV1 (37% predicted) and FVC (45% predicted) with a decreased FEV1/FVC ratio. Diffusing capacity was reduced (72% predicted). Barium swallow and repeat computed tomography of the thorax were unrevealing. Right heart catheterization demonstrated a mean pulmonary artery pressure of 18-mmHg and a normal cardiac index. Bronchoscopy revealed thickening of the mucosa throughout the tracheobronchial tree (Figure 2). Histopathologic examination of endobronchial biopsies demonstrated smooth muscle hypertrophy of the larger airways. Given the confirmation of smooth muscle proliferation in three organ systems, the patient was referred to a genetic counselor for further testing. Chromosomal microarray confirmed a deletion of Xq22.3 encompassing genes COL4A6 (X-linked diffuse leiomyomatosis) and COL4A5 (Alport syndrome). The patient’s obstructive disease improved with bronchodilators and inhaled steroids.

DISCUSSION: Diffuse leiomyomatosis is a rare phenomenon characterized primarily by hypertrophy of the esophageal wall, but may also involve tracheobronchial wall and female genitalia (2). Tracheobronchial leiomyomatosis has been reported in only four cases at autopsy (2).

CONCLUSIONS: Although airway smooth muscle cell hypertrophy may also be seen in patients with asthma, our case underscores the importance of further investigation when multiple sites of abnormalities are confirmed.

1) Benayoun, L. et. al. Airway structural alterations selectively associated with severe asthma. Am J Respir Crit Care Med 2003;167:1360-1368.

2) Garcia-Torres, R. et. al. Alport syndrome and diffuse leiomyomatosis. Nephrologie 2009;21:9-12.

DISCLOSURE: The following authors have nothing to disclose: Jamie Bessich, James Carroll, Lisa Tilluckdharry

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Dartmouth-Hitchcock Medical Center, Lebanon, NH
Chest. 2012;142(4_MeetingAbstracts):6A. doi:10.1378/chest.1388580

SESSION TYPE: Airway Case Report Posters

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Adenoid Cystic Carcinoma (ACC), also known as cylindroma, is a rare primary tracheal tumor, which comprises 0.1 - 0.2% of all lung cancers (1). Histologically, the majority of the tracheal tumors are squamous cell carcinomas, but ACC and mucoepidermoid carcinoma are seen in rare instances. We report a unique case of an elderly woman with wheezing who was found to have ACC.

CASE PRESENTATION: 88 year old female, former smoker with history of COPD, CHF and atrial fibrillation presented with shortness of breath and cough for 4 weeks .Physical examination was notable for labored breathing and bilateral wheezing. Patient was treated initially for a COPD exacerbation with intravenous steroid and nebulizers without improvement. Chest x-ray showed a right mid lung density and CAT scan of the chest showed a nodular 2.4 cm mass protruding into the trachea and a 4 cm solid opacity in the right mid-lung. Patient underwent flexible bronchoscopy and was found to have large endotracheal mass. Fine needle aspiration cytology revealed neoplasm of minor salivary gland, favoring ACC. The mass subsequently was removed via rigid bronchoscopy and the patient was discharged home .

DISCUSSION: ACC is the 2nd most common primary tracheal neoplasm. It usually arises in the proximal one-third or distal one-third of the trachea and has no association with tobacco exposure (2). ACC has a slow growing and prolonged clinical course; it is considered to be a low-grade malignancy and identical to ACC of the salivary glands (3). Most ACCs are discovered in middle age with no gender predilection .The common presenting symptoms of cough, dyspnea, hoarseness and wheezing are usually related to the size and location of the mass (3). Surgery is the standard treatment of tracheal tumors if possible and the rate of recurrence after resection is high. The tumor is relatively radiosensitive and post-operative radiotherapy may have some effect on local control but treatment does not affect overall survival rate.

CONCLUSIONS: Our patient demonstrates a rare case of ACC (cylindroma) of the trachea that was initially mis-diagnosed and treated for COPD exacerbations. Physicians should be aware of ACC of the trachea as a rare cause of persistent airway obstruction.

1) Ahn Y, Chang H, Lim YS, et al. Primary tracheal tumors: review of 37 cases. J Thorac Oncol 2009; 4:635

2) Maziak DE, Todd TR, Keshavjee SH, et al. Adenoid cystic carcinoma of the airway: thirty-two-year experience. J Thorac Cardiovasc Surg 1996; 112:1522

3) Webb BD, Walsh GL, Roberts DB, Sturgis EM. Primary tracheal malignant neoplasms: the University of Texas MD Anderson Cancer Center experience. J Am Coll Surg 2006; 202:237

DISCLOSURE: The following authors have nothing to disclose: Emile Klada, Ruchi Bansal, Juan George, Lavanya Irugulapati, Thomas Russi

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New York Methodist, Brooklyn, NY
Chest. 2012;142(4_MeetingAbstracts):7A. doi:10.1378/chest.1360071

SESSION TYPE: Airway Case Report Posters

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Ulcerative colitis (UC) has a rare, but well-documented, association with pulmonary disease. We present a case of a patient with progressive bronchiectasis due to ulcerative bronchitis following colectomy.

CASE PRESENTATION: A female 50 year old former smoker initially presented with new onset UC. Her disease was poorly controlled with immunosuppressive agents, and she underwent a total colectomy. Two years later, she presented with cough, shortness of breath, and wheeze. Obstructive dysfunction was detected and bronchodilator therapy was initiated with partial relief of symptoms. Chest CT was notable for centrilobular nodules, mild bronchiectasis, and peribronchial wall thickening. The patient’s clinical and respiratory status progressively worsened. Sputum cultures grew Mycobacterium avium-complex (MAC), and therapy with clarithromycin, ethambutol, and rifampicin was initiated. Cultures converted negative, but following an initial period of radiographic and clinical improvement, the patient again began to experience increased cough, SOB, sputum production, as well as constitutional symptoms. Inhaled amikacin and hypertonic saline were added to her regimen. The patient’s clinical and respiratory status progressively deteriorated despite clearance of MAC from sputum cultures, and further chest imaging revealed markedly progressed bronchiectasis and bronchial wall thickening with bronchiolitis. Bronchoscopy revealed severe edema, inflammation, and cobblestoning of the trachea and proximal airways. Large and medium airway biopsies showed severe submucosal inflammation, lymphoplasmacytic infiltration, squamous metaplasia, and peribronchial fibrosis. Findings were consistent with ulcerative bronchitis. The patient subsequently underwent wedge resection of her severely bronchiectatic RML. Surgical cultures were negative, and there is a plan to initiate immunosuppressive therapy for treatment of her UC-related lung disease.

DISCUSSION: Pulmonary involvement in UC may involve small and large airways, parenchyma, or serosa. Airway and colonic inflammation in UC are likely mediated by the same mechanism, probably owing to shared embryonic origins. Respiratory symptoms unresponsive to usual therapies may precede diagnosis, and the pulmonary manifestations of UC may progress independently of intestinal disease and occur years after colectomy. Importantly, many drugs which are used to treat UC can induce pulmonary hypersensitivity or toxicity. Treatment of ulcerative bronchitis involves immunosuppressive therapy, usually with glucocorticoids and/or steroid sparing agents. This should only be considered once potentially offending medications have been withdrawn and superimposed infections have been eradicated.

CONCLUSIONS: In patients with UC and unexplained respiratory complaints, consider UC-related pulmonary disease.

1) Black H, et al. Chest 2007;131:524.

2) Storch I, et al. Inflammatory Bowel Disease 2003;9(2):104.

3) Camus P, et al. Medicine 1993:72:151.

DISCLOSURE: The following authors have nothing to disclose: Benjamin Seides, Kenneth Olivier, Charles Daley, Doreen Addrizzo-Harris

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Division of Pulmonary & Critical Care Medicine, NYU School of Medicine, New York, NY
Chest. 2012;142(4_MeetingAbstracts):8A. doi:10.1378/chest.1389381

SESSION TYPE: Airway Case Report Posters

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Pulmonary sequestration is a rare phenomenon with complex anatomical variations (2). Sequestered areas have embryological origins and traditionally do not communicate with the lung via normal bronchogenic pathways, but rather through pores of Kohn (3). We present a case of pulmonary sequestration with histopathology demonstrating communication of sequestered segments with normal bronchioles.

CASE PRESENTATION: A 25-year-old female presented to her primary care physician secondary to persistent dry cough, low grade fevers, chills, and fatigue of two weeks duration. She was treated for an upper respiratory tract infection, but continued to deteriorate. A chest radiograph demonstrated a right lower lobe consolidation. Due to poor response to antibiotic treatment, computerized tomography of the thorax was obtained, which revealed a dense consolidation in the right base with surrounding cystic areas. The lung architecture appeared abnormal in the consolidated segments, with a distinct blood supply from a bronchial artery originating from the abdominal aorta. A diagnosis of intralobar pulmonary sequestration was made. The patient was referred for resection of the infected abnormal lung tissue. An intraoperative bronchoscopy was performed prior to surgery to assess the affected segments. Abnormal airways with purulent secretions were noted in the right lower lobe basilar segments. Thoracotomy and resection of the sequestered area was performed without complications. Post-operative recovery was uneventful, and the patient improved dramatically. Pathological analysis of the dissected specimen demonstrated multiple cystic, bronchiectatic pathways with diffuse areas of necrotizing and non-necrotizing granulomatous inflammation that appeared to communicate with normal lung. Bronchoalveolar lavage cultures from the right lower lobe grew Mycobacterium avium-intracellulare (MAI).

DISCUSSION: In this patient with pulmonary sequestration, cystic pathways identified during surgery demonstrated abnormal communication with normal bronchioles. Infection persisted in these segments despite antibiotic treatment because of poor clearance and abnormal architecture and hence necessitated surgical resection (1).

CONCLUSIONS: Anomalies secondary to pulmonary sequestration are prone to complications and require careful investigation prior to surgical resection secondary to variable anatomic properties (3).

1) Kaneko, S et. al. Pulmonary sequestration in older child and in adults. Int Surg 1992 Apr-Jun;77(2):102-7.

2) Louie, H. et. al. Pulmonary sequestration: 17-year experience at UCLA. Am Surg. 1993 Dec;59(12):801-5.

3) Sade, R. et. al. The spectrum of pulmonary sequestration Ann Thorac Surg 1974;18:644-658.

DISCLOSURE: The following authors have nothing to disclose: Aamir Gilani, Jamie Bessich, Donald Mahler

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Dartmouth-Hitchcock Medical Center, Lebanon, NH
Chest. 2012;142(4_MeetingAbstracts):9A. doi:10.1378/chest.1385756

SESSION TYPE: Airway Case Report Posters

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Patients developing toxic epidermal necrolysis (TEN) may have a variety of manifestations of this reactive process on different mucosal barriers. When involving pulmonary tissues they are often acute and associated with the onset of the dermatologic manifestations. Secondary effects of TEN on the lung are rarely reported, although there are several case reports of late pulmonary complications arising days to weeks after resolution of dermatologic manifestations. The long-term prognosis in those cases is poor due to severe airway obstruction.

CASE PRESENTATION: We present the case of a 19-year-old male who presented with new-onset dyspnea several weeks following his recovery from TEN due to multiple antibiotics. He reported no pulmonary complications during his 48 hour hospitalization. His initial pulmonary evaluation showed a very severe obstruction with a FEV1 of 1.13L (27% predicted), and lung volumes showed a total lung capacity that was 91% predicted with a residual volume elevated to 245% predicted. He was also found to have a completely collapsed left lower lobe (LLL) on initial chest radiograph while his right lung appeared hyperinflated. Subsequent high resolution chest tomography showed a mosaic pattern consistent with the bronchiolar pattern consistent with bronchiolitis obliterans. Over the weeks that followed his spirometry remained fairly stable while his lung volumes steadily decreased. He later became hypoxic at rest, and he eventually developed marked atelectasis in the left upper lobe along with a collapsed LLL. Further workup failed to show any vascular, infectious, endobronchial, or hematologic cause for his hypoxia. Therefore, he was given a trial of steroids which failed to illicit any improvement. Thus, given his progressive hypoxia, suspected bronchiolitis, and lack of other identifiable causes he was referred for lung transplant.

DISCUSSION: Although not widely seen with TEN, or similarly Stevens-Johnson-type reactions, late pulmonary complications have been described and often such complications have both high morbidity and mortality. One recent case review by Kamada, et.al. describes a somewhat similar case, and references several historically similar cases. In these cases the clinical appearance, following initial recovery from TEN, was generally of severe airway obstruction with pathologic findings of bronchiolitis obliterans.

CONCLUSIONS: Our case appears to mimic these historic cases and suggest an as yet unknown inflammatory process leading to progressive pulmonary failure following these reactions.

1) Kamada N, et al. Chronic pulmonary complications associated with toxic epidermal necrolysis: Report of a severe case with anti-Ro/SS-A and a review of the published work. Journal of Dermatology 2006; 33: 616-622

DISCLOSURE: The following authors have nothing to disclose: William Porr, Julia Morgan

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San Antonio Military Medical Center, San Antonio, TX
Chest. 2012;142(4_MeetingAbstracts):10A. doi:10.1378/chest.1390822

SESSION TYPE: Airway Case Report Posters

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Unlike infectious epiglottitis, thermal epiglottitis is a rare condition. We present an interesting and rare case of thermal epiglottitis.

CASE PRESENTATION: 47 year old woman presented to the emergency room with acute stridor. Earlier she rolled a cigarette using tobacco leftovers from previously smoked cigarettes. She experienced lip and oropharyngeal burning followed by hypersalivation, stridor, voice changes, and dyspnea. A lateral xray of the neck demonstrated marked epiglottal swelling with airway narrowing. Direct laryngoscopy revealed severe supraglottic edema of the epiglottis and tracheal opening. She was intubated for airway protection using a bougie and 6.5 French endotracheal tube. Bronchoscopy showed no evidence of bronchial soot or inhalation injury. She was extubated 2 days later.

DISCUSSION: Thermal epiglottitis is a medical emergency. The radiographic and laryngoscopic findings are similar to those of infectious epiglottitis. In a series of 407 epiglottitis cases, Mayo-Smith et al. found only 4 cases of thermal epiglottitis, all from inhalation of heated objects when smoking illicit drugs. The symptoms were mostly sore throat, dysphagia, voice changes, drooling, and respiratory distress. The principles of management of thermal epiglottitis involve airway maintenance and antibiotics until an infectious etiology has been excluded. There is a consensus on placing an artificial airway in children with epiglottitis even in the absence of respiratory distress. In adults, a selective approach is followed. Adult patients with less than 50% laryngeal obstruction and absence of respiratory distress can be observed in the intensive care unit (ICU) without artificial airway. Prior to extubation, patients should demonstrate an endotracheal tube cuff leak and a resolution of edema on laryngoscopy. The role of steroids is controversial and was not associated with a reduction in length of stay, duration of intubation, or duration of ICU stay.

CONCLUSIONS: Thermal epiglottitis is an unusual cause of threatened airway obstruction. While the role of antibiotics and steroids is not clear, airway maintenance remains the mainstay of management.

1) Mayo-Smith MF, Spinale J. Thermal epiglottitis in adults: a new complication of illicit drug use. J Emerg Med. 1997 Jul-Aug;15(4):483-5.

2) Glynn F, Fenton JE. Diagnosis and management of supraglottitis (epiglottitis). Curr Infect Dis Rep. 2008 May;10(3):200-4.

3) Wolf M, Strauss B, Kronenberg J, Leventon G. Conservative management of adult epiglottitis. Laryngoscope. 1990 Feb;100(2 Pt 1):183-5.

DISCLOSURE: The following authors have nothing to disclose: Labib Debiane, George Nassif, Rami Zebian, Saadia Faiz, William Fisher

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University of Texas Health Science Center in Houston, Houston, TX
Chest. 2012;142(4_MeetingAbstracts):11A. doi:10.1378/chest.1385598

SESSION TYPE: Airway Case Report Posters

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Increased placement of esophageal stents for the palliative management of malignant esophageal strictures has resulted in increased complications. We report a case of tracheoesophageal fistula formation from esophageal stent erosion and subsequent tracheal and esophageal double stenting with good clinical outcome.

CASE PRESENTATION: A 41-year old female with metastatic cervical cancer, gastritis, and recent placement of esophageal stent presented with sudden onset respiratory failure. Pt was diagnosed with stage II B cervical cancer and treated with chemo and radiation therapy. She had reoccurrence of disease a year later with metastasis to liver, retroperitoneum, and thoracic spine. Pt had increasing dysphagia and EGD done 7 days prior showed almost complete esophageal obstruction with stricture 30 cm from incisors. A 60mmx18mm esophageal stent was placed during EGD and Pt was recovering well when sudden respiratory failure occurred. Despite direct laryngoscopy intubation, Pt remained hypoxic with 100% inspired oxygen and 14cm PEEP. Exam showed hyperresonance over epigastrim with poor chest excursion. On bronchoscopy, a tracheoesophageal fistula was seen in the distal trachea (Fig.1) where the proximal end of the esophageal stent (Fig.2) was observed eroding through the posterior tracheal wall. Pt had esophageal stent removed and a longer 18mmx160mm stent was deployed across the defect with a second 14x40mm tracheal stent placed at the distal trachea. She was extubated 2 days later and subsequently discharged home in stable condition.

DISCUSSION: Esophageal stents have proven useful in the management of esophageal strictures despite complications approaching 30-35% including prosthesis migration, new stricture formation, and esophageal erosion with fistula formations. Most tracheoesophageal fistulas present more than a week after stent placement with unrepaired defects leading to poor nutrition, repeat aspirations, and recurrent pneumonia followed by rapid clinical deterioration and death. Studies have examined management of malignant tracheoesophageal fistulas with combined airway and esophageal stenting leading to increased quality of life. Early recognition of stent complication and fistula formation provides a window of opportunity through which satisfactory clinical outcome can be attained.

CONCLUSIONS: Tracheoesophageal fistulas should be considered in acute respiratory compromise following esophageal stent placement where early recognition can lead to immediate and improved patient outcome.

1) Sharma P, Kozarek R. Role of esophageal stents in benign and malignant diseases. Am J Gastroenterol 2010; 105:258-273.

2) Herth FJ, Peter S, Baty F, Eberhardt R, Leuppi JD, Chhajed PN. Combined airway and oesophageal stenting in malignant airway-oesophageal fistulas: a prospective study. Eur Respir J. 2010; 36(6):1370-4.

DISCLOSURE: The following authors have nothing to disclose: Irene Hao, Leandro Leacina

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UMDNJ - University Hospital, Newark, NJ
Chest. 2012;142(4_MeetingAbstracts):12A. doi:10.1378/chest.1385951

SESSION TYPE: Airway Case Report Posters

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Acute epiglottitis is an uncommon, rapidly progressive form of cellulitis of the epiglottis and adjacent structures that can result in complete and potentially fatal airway obstruction. Because of the danger of airway obstruction, acute epiglottitis constitutes a medical emergency. The diagnosis is often clinical, although direct fiberoptic laryngoscopy is frequently performed for culture and visualization. We present a case of a 43 year old male with acute epiglottitis that required emergent cricothyroidotomy.

CASE PRESENTATION: Forty-three year old male with a 3 day history of pharyngitis, fever, malaise, odynophagia, and yellow sputum production. ENT evaluated the patient with direct fiberoptic laryngoscopy, which showed diffuse edema of the right oropharynx down to supraglottis with edema of the pyriform. Shortly after, the patient decompensated with stridor, hypoxemia and respiratory arrest. Endotracheal intubation was attempted by direct larnygoscopy, glidescope and bronchoscope by multiple subspecialists without success. An emergent surgical airway was obtained with a cricothyroidotomy. Patient received treatment with dexamethasone and IV antibiotics. Of the microbiologic data obtained, only the Rapid Strep test was positive. Repeat direct visualization 5 days later showed a purulent epiglottis with edema and erythema. The patient underwent a surgical tracheostomy. His oxygenation improved and he completed a course of intravenous antibiotic therapy. The patient was later discharged home with a tracheostomy and outpatient follow up.

DISCUSSION: Epiglottitis is an uncommon disease with an incidence in adults of about 1 case /100,000 per year. Adult epiglottitis is most frequently seen in men in their fifth decade. Once considered as a pediatric disease, there has been a dramatic decrease in children since the introduction of the Hib vaccine. Adult cases have remained constant. With the decrease in Hemophilus infections, Streptococcus species are now the most common pathogens in this disease. Epiglottitis can lead to rapid deterioration and upper airway obstruction, thus involvement of ENT and Anesthesia early in patient care are key to successful management.

CONCLUSIONS: Acute epiglottitis is a medical emergency and a multidisciplinary approach is part of management due to the complexity and potential complications. Antibiotic therapy should be broad to cover Hib and streptococcal species. If not suspected or identified promptly, obstruction of the airway can rapidly develop and be lethal. An emergent surgical airway is always a consideration in the setting of respiratory distress and an inability to obtain endotracheal intubation.

1) Guldfred, LA. Acute epiglottitis:epidemiology, clinical presentation, management and outcome. The Journal of Laryngology & Otology 2008, 122, 818-823.

DISCLOSURE: The following authors have nothing to disclose: Karla Diaz, Adriel Malave

No Product/Research Disclosure Information

University of Texas Health Science Center at San Antonio, San Antonio, TX
Chest. 2012;142(4_MeetingAbstracts):13A. doi:10.1378/chest.1369876

SESSION TYPE: Airway Global Case Report Posters

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Even though mediastinal neurofibromas are common, intrapulmonary neurofibromas are rare. Nodular shadows in the chest x-rays of neurofibromatosis are often due to the lesions in the chest wall. In this paper, we present a case of intrathoracic neurofibroma with intrabronchial extension. Lesions extending into the bronchial lumen making bronchoscopic diagnosis possible, as in this case is extremely rare.

CASE PRESENTATION: A 24 year old female presented with cough and breathlessness of 1 month duration. She had extensive neurofibromatosis. The chest X-ray showed multiple nodular shadows in the right hemithorax with left pleural effusion . CT thorax confirms that the nodules are intrapulmonary in location. Fiber optic Bronchoscopy revealed multiple nodular swellings in the both main bronchi partially compressing the lumen. Multiple biopsies were taken from these endobronchial lesions. The histopathology picture of bronchoscopic biopsy specimen was consistent with neurofibroma in the airways.

DISCUSSION: Neurofibromas are benign tumors arising from neural crest cells and may arise in any peripheral nerve. They can be solitary or multiple (Neurofibromatosis). The tumors may cause subcutaneous nodules, colored spots, skeletal problems, pressure on spinal nerve roots, and other neurological problems. Neurogenic tumors account for about 9% of primary mediastinal masses in adults and 30% of mediastinal tumors in children. Neurofibromas may involve the mediastinum extensively and can become quite large and have pressure effects on thoracic structures like trachea, superior vena cava and oesophagus2. They typically appear as well-marginated, smooth, round or elliptic masses in the paravertebral regions or along the course of the vagus, phrenic, recurrent laryngeal or intercostal nerves. In CT, they appear as well-defined subcutaneous neurofibromas, focal thoracic scoliosis, posterior vertebral scalloping, enlarged neural foramina, and characteristic rib abnormalities due to bone dysplasia or erosion from adjacent neurofibromas. They show variable contrast material enhancement and may calcify. They can result in diffuse mediastinal widening and may mimic lymphoma, sarcoid, lymphangiomatosis, and metastatic disease3. However, neurogenic benign tumors arising from the trachea and bronchus are relatively rare. Hidemi Suzuki4 et al have reported three cases of neurofibroma of the bronchus which were successfully treated by transbronchial electrical snaring and Nd-YAG laser abrasion. NF-associated ILD Neurofibromatosis with diffuse lung disease is a distinct clinical entity, characterized by upper lobe cystic and bullous disease and basilar fibrosis. Pulmonary function tests show either an obstructive or a restrictive defect, and a decreased DLCO is almost always present. HRCT appearance in NF-DLD commonly report large apical asymmetric thin-walled bullae, cystic changes and emphysema5. Histopathology is consistent with nonspecific idiopathic pneumonia (NSIP) pattern. Because there is no cure for neurofibromatosis, the only therapy is a program of treatment by a team of specialists to manage symptoms or complications. Surgery may be needed when the tumors compress organs or other structures. Less than 10% of people with neurofibromatosis develop cancerous growths; in these cases, chemotherapy may be successful.

CONCLUSIONS: Even though mediastinal neurofibromas are common, intrapulmonary neurofibromas are very rare. In this paper, we present a case of intrathoracic neurofibroma with intrabronchial extension. Lesions extending into the bronchial lumen making bronchoscopic diagnosis possible, as in this case is extremely rare. The case is presented because of its rarity.

1) Marchuk DA, et al. DNA Cloning of the Type-1 Neurofibromatosis Gene - Complete Sequence of the NF1 Gene Product. Genomics 11:931-940.

2) R El Oakley G J Grotte Progressive tracheal and superior vena caval compression caused by benign Neurofibromatosis, Thorax 1994; 49:380-381.

3) Brian J. Fortman, Brian S. Kuszyk,Bruce A. Urban, and Elliot K. Fishman. Neurofibromatosis Type 1: A Diagnostic Mimicker at CT, May 2001 RadioGraphics, 21,601-612.

DISCLOSURE: The following authors have nothing to disclose: Venugopal Panicker, Raseela Karunakaran

No Product/Research Disclosure Information

Govt TD Medical College, Alappuzha, India
Chest. 2012;142(4_MeetingAbstracts):14A. doi:10.1378/chest.1373769

SESSION TYPE: Airway Global Case Report Posters

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Asthma is an inflammatory disease of the lower respiratory tract, manifesting as intermittent constriction of the bronchial airways. Obstructive sleep apnea (OSA),-hypopnea syndrome, on the other hand is defined as the presence of at least five obstructive events per hour with associated daytime sleepiness. A relationship between asthma and OSA was noted more than 25 years ago. Multiple putative pathways for OSA aggravation of asthma exist. First, OSA could promote GERD, a well-recognized asthma trigger. Second, direct links may exist through OSA-related increase in the resistive load on lower airways imposed on an already more challenged airway system especially during sleep. This occurs via upper-airway-triggered vagally mediated bronchoconstriction, and increased bronchial responsiveness. Finally,OSA may lead to oxidative stress and inflammation in the lower airway. There is a high OSA risk in not well controlled asthma.

CASE PRESENTATION: A 53yr old obese, hypertensive known asthmatic presented to us with breathlessness. He gave history of repeated hospital admissions , frequent night time arousals, excessive day time sleepiness and was a loud snorer. He had progressively worsening of symptoms inspite of appropriate treatment. On a high clinical suspicion of OSA, sleep study was performed. He had AHI index of 31.4/hr, frequent arousals 8.8/hr with minimal saturation 51% and breath with flow limitations 0.2ml/hr in non supine position. He had early REM latency but desaturations and apnenic events occurred in left position. Thus a diagnosis of severe OSA with asthma was made. Patient was started on CPAP at a pressure of 10.4 cm of water with nasal mask with oxygen 2 L/min via mask. His pre and post ABG values were as follows:- PARAMETERS, PRE CPAP, POST CPAP pCO2 , 48mm hg , 24mm hg pO2 , 58.3mm hg , 84.4mm hg Ph , 7.42 , 7.48 Patient showed dramatic improvement and is on regular follow up with no complaints since one year.

DISCUSSION: Studies have shown that OSA is an independent risk factor for asthma, and OSA is more common in asthmatics than in the general population. Studies of CPAP treatment of PSG-diagnosed OSA in patients with asthma reports improved asthma outcomes hence Practitioners should be especially vigilant of OSA symptoms in unstable, poorly controlled asthmatic patients, especially when obesity is present.

CONCLUSIONS: Obstructive sleep apnea (OSA) and asthma are detrimental to each other” is the conclusion of a recent review of links between the two conditions.

1) Bearpark H, Elliott L, Grunstein R, et al. Snoring and sleep apnea: A population study in Australian men. Am J Respir Crit Care Med 1995;151:1459-65.

2) Zanation AM , Senior BA . The relationship between extraesophageal reflux (EER) and obstructive sleep apnea (OSA) . Sleep Med Rev 2005;9(6):453-458 .

3) Harding SM. Gastroesophageal refl ux: a potential asthma trigger. Immunol Allergy Clin North Am . 2005;25(1):131-148.

DISCLOSURE: The following authors have nothing to disclose: Amitesh Gupta, Saurabh Kansal, Parul Mrigpuri, A.p. Kansal

No Product/Research Disclosure Information

Govt. Medical College, Patiala, India
Topics: asthma
Chest. 2012;142(4_MeetingAbstracts):15A. doi:10.1378/chest.1381827

SESSION TYPE: Airway Global Case Report Posters

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: A 38 years old man presented a chronic upper right lobe atelectasis complicated by recent infection. After completing diagnostic workup, excluding infection, autoinmune disease and neoplasm, an unexpected diagnosis of tracheobronchial amyloidosis came up.

CASE PRESENTATION: A 38 year old man was admitted to hospital with a 72 hours of fever (38 C), left chest pain and dyspnea MRC 3. He was mild hypoxemic, a right upper lobe atelectasis and a left basal consolidation was evident on the chest X Ray. By patient referral the right atelectasis was present since 3 years, and had undergone two previous bronchoscopies in another institution without diagnostic yield. Antibiotic therapy was established with ressolution of the left consolidation and persistance of the right atelectasis. Thoracic CT and Bronchoscopy were performed. On CT: Concentric and diffuse thickening of trachea, main , segmental and subsegmental bronchi walls. Upper right lobe bronchial stenosis with total lobe atelectasis. Bronchoscopy: right upper lobe bronchus occupied by tumor-like formation that was biopsed. Lateral basal segment of left lower lobe with a thickened lobar carina with infiltrative appearance. Biopsy showed: Deposit of amorphous eosinophilic hyaline material which stained with Congo red and refracted under polarized light greenish yellow. An Amyloidosis diagnosis was confirmed. Immunohistochemistry was consistent with AA amyloidosis. No other systemic compromise was found.

DISCUSSION: Tracheobronchial amyloidosis is an uncommon diagnosis. Airway involvement may be focal, multifocal, or diffuse. Diffuse involvement is most common as in this case (1). Affected patients are often asymptomatic for a long time before diagnosis, which suggests that the disease progresses relatively slowly. Narrowing of the airways can cause distal atelecatasis or recurrent pneumonia (2). Endoscopic examination of the disease shows either submucosal plaques and nodules with a cobblestone appearance or a tumor-like appearance or circumferential wall thickening. Endoscopic biopsies are diagnostic. Deposition of amyloid in the tracheal bronchi may be seen in association with systemic amyloidosis or as an isolated manifestation.

CONCLUSIONS: Nonneoplasic central airway disease must be considered as a cause of chronic atelectasis. Tracheobronchial amyloidosis has inespecific clinical symptoms. Chest CT helps in diagnostic suspicious. Biopsy confirms diagnosis.

1) Nonneoplastic Tracheal and Bronchial Stenoses. Philippe A. Grenier, Catherine Beigelman-Aubry, Pierre-Yves Brillet. PhDb Radiol Clin N Am: 47 (2009) 243-260.

2) Amyloidosis and the respiratory tract .Julian D Gillmore, Philip N Hawkins,Thorax 1999;54:444-451

DISCLOSURE: The following authors have nothing to disclose: Patricia Malamud, Eduardo Giugno, Valeria Morandi, Nicolas Itcovici, Santiago Rossi, Andrea Werbach

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Hospital Dr. Antonio A. Cetrángolo, Buenos Aires, Argentina
Topics: atelectasis
Chest. 2012;142(4_MeetingAbstracts):16A. doi:10.1378/chest.1385291

SESSION TYPE: Airway Global Case Report Posters

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Gastroesophageal reflux induced cough is a common cause of chronic cough, and proton pump inhibitors are a standard therapy. However, the patients unresponsive to the standard therapy are difficult to treat and remain a challenge to doctors. Here, we summarized the experience of successful resolution of refractory chronic cough due to gastroesophageal reflux with baclofen in a patient. It is concluded that baclofen may be a selectable option for gastroesophageal reflux induced cough failing to proton pump inhibitor therapy.

CASE PRESENTATION: A 26-year-old male patient with persistent cough for 3.5 years was referred to our respiratory clinic. A further 24-hour esophageal pH monitoring revealed an abnormal acid-reflux with a DeMeester score of 61.4 and the symptom association probability of 99%. Then, the presumptive diagnosis of GERC was established and oral omeprazole 20 mg twice a day was commenced. The patient’s cough persisted despite the subsequent treatment with oral montelukast and inhaled corticosteroid. Since no relief of cough was observed, multi-channel intraluminal impedance combined with pH monitoring was ordered, and the abnormal non-acid reflux and positive symptom association probability for non-acid reflux was found (Table 1). After 8 week of additional augmented antireflux medical therapy comprising omeprazole, 20 mg twice a day and domperidone, 10 mg three times a day, the patient did not feel any improvement. Then, baclofen, 20 mg three times a day was used to replace domperidone. His cough attenuated obviously in a week, and completely resolved in two months, as indicated by the decreased cough symptom score and cough reflex sensitivity to capsaicin (Figure 1, 2). Within the next four months of follow-up, no reoccurrence of cough was reported. The dosage of baclofen was currently reducing to 20 mg daily. No discernable side effects were noted during the treatment with baclofen.

DISCUSSION: In theory, the therapeutic options available for non-acid GERC resistant to proton pump inhibitors include prokinetic agents, transient lower esophageal sphincter relaxation inhibitors and antireflux surgery because they all have the ability to reduce the frequency of reflux and volume of refluxate. At present, the efficacy of prokinetic agents has not been ascertained. Antireflux surgery should not be the preferred choice since a cause and effect relationship between reflux and chronic cough is not definitely established. As transient lower esophageal sphincter relaxations account for the vast majority of reflux events, 4 baclofen, a potent inhibitor of transient lower esophageal sphincter relaxation, may be selected as an add-on trial for GERC unresponsive to proton pump inhibitors. To our knowledge, it is the first report for successful resolution of refractory GERC with baclofen even though there has been several studies on its use in the difficult to treat gastroesophageal reflux disesase.

CONCLUSIONS: Baclofen may be a selectable option for refractory cough due to gastroesophageal reflux. Further study is needed to validate its therapeutic efficacy for GERC in the future.

1) Irwin RS. Chronic cough due to gastroesophageal reflux disease: ACCP evidence-based clinical practice guidelines. Chest, 2006, 129: 80S-94S. 2. Boeckxstaens GE, Smout A. Systematic review: role of acid, weakly acidic and weakly alkaline reflux in gastro-oesophageal reflux disease. Aliment Pharmacol Ther, 2010, 32: 334-343. 4. Boeckxstaens GE. Reflux inhibitors: a new approach for GERD? Curr Opin Pharmacol, 2008, 8: 685-689. 5. Beaumont H, Boeckxstaens GE. Does the presence of a hiatal hernia affect the efficacy of the reflux inhibitor baclofen during add-on therapy? Am J Gastroenterol, 2009, 104:1764-1771. 6. Zhang Q, Lehmann A, Rigda R, et al. Control of transient lower oesophageal sphincter relaxations and reflux by the GABA(B) agonist baclofen in patients with gastro-oesophageal reflux disease. Gut, 2002, 50: 19-24. 8. Vela MF, Tutuian R, Katz PO, et al. Baclofen decreases acid and non-acid post-prandial gastroesophageal reflux measured by combined multichannel intraluminal impedance and pH. Aliment Pharmacol Ther, 2003, 17: 243-251.

DISCLOSURE: The following authors have nothing to disclose: Xianghuai Xu, Zhong-min Qiu, Han-jing Lv, Qiang Chen, Si-wei Liang

No Product/Research Disclosure Information

Shanghai Tongji Hospital, Shanghai, China
Chest. 2012;142(4_MeetingAbstracts):17A. doi:10.1378/chest.1389039

SESSION TYPE: Airway Global Case Report Posters

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Kartagener syndrome is a rare, ciliopathic, autosomal recessive genetic disorder that causes a defect in the action of the cilia lining the respiratory tract and fallopian tube. Patients usually present with chronic recurrent rhinosinusitis, otitis media, pneumonia, and bronchiectasis usually caused by pseudomonal infection. Situs inversus can be seen in about 50% of cases. We present a case of a 9-year-old boy with chronic recurrent upper respiratory infections. He was diagnosed with Kartagener syndrome based on his clinical presentation and radioimaging Keywords: bronchiectasis, immotile cilia syndrome, situs inversus

CASE PRESENTATION: A 9 year old male child admitted in our hospital, presenting with recurrent nasal blockade, cough with expectoration and intermittent fever since early infancy. His previous records showed a lot of investigations for tuberculosis and examinations of the sputum. On examination he was febrile with wheezy chest and bilateral coarse crackles. Initial suspicion was that of bronchial asthma with recurrent chest infections or pneumonia but the possibility of other causes were also kept in mind. His heart sounds were heard best on the right side of the chest. On further work up, basic investigations were under normal limits and in ECG and radiological imaging following were observed, Chest X Ray showed dextrocardia with gastric bubble on right side and liver dullness on left side.ECG showed tall R waves in lead V1 and absent R waves in V4,V5 and V6, Chest Tomography showed Total Situs Inversus with Liver on rleft side and spleen and stomach on right side. Lung parenchyma showed bronchiectatic changes mainly in posterior basal segments of left lower lobes while CT PNS showed B/L maxillary Sinusitis, mucosal thickening in both maxillary sinuses with opacified frontal sinusitis while ECHO showed trivial MR with TR

DISCUSSION: Although there is no specific treatment for this condition, failure to recognize the condition may subject the patient to unnecessary repeated admissions and investigations and inappropriate treatment.

CONCLUSIONS: Considering the patient clinically, along with sinusitis,bronchiectasis and situs inversus, the clinical diagnosis of Kartagener's syndrome was made. By early diagnosis of this rare entity, patient and his family is saved from unnecessary investigations and inappropriate treatment and later in life when child will attain puberty it is advisable to go under semen analysis that may affect his marital life considering social impact of this entity.

1) Kartagener M.. Zur Pathogenese der Bronchiektasien: Bronchiektasien bei Situs viscerum inversus. Beitr Klin Tuberk 1933; 83:489-501.

2) None PG, Bali D, Carson JL Sannuti A, Gipson CL, Ostrowski LE, et al. Discordant organ laterality in monozygotic twins with primary ciliary dyskinesis. Am J Med Genet 1999; 82: 155-60.

3) Ellis DA, Thornley PE, Wightman AJ, Walker M, Chalmers J, Crofton FW. Present outlook in bronchiectasis: clinical and social study and review of factors influencing prognosis. Thorax 1981;36:659-64

DISCLOSURE: The following authors have nothing to disclose: Saurabh Kansal, Gopal Chawla, A.p. Kansal, Amitesh Gupta

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Govt. Medical College, Patiala, India
Chest. 2012;142(4_MeetingAbstracts):18A. doi:10.1378/chest.1389294

SESSION TYPE: Airway Global Case Report Posters

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Primary ciliary dyskinesia (PCD), also known as immotile ciliary syndrome or Kartagener Syndrome (KS), is a rare, ciliopathic, autosomal recessive genetic disorder that causes a defect in the action of the cilia lining the respiratory tract (lower and upper, sinuses, Eustachian tube, middle ear) and fallopian tube, and also of the flagella of sperm in males. There is no statistics for the prevalence of this disease in the Saudi population. We presented the case of this geneticaly transmitted rare disorder in a saudi male.

CASE PRESENTATION: We present a case of a 19 year old saudi male patient with PCD whose chief complaint is recurrent respiratory symptoms of cough, dark sputum expectoration.past medical history is positive childhood repeated respiratory infections, and nasal symptoms of dryness, congestion, and repeated sinus infections.the patient used several antibiotics, and nasal decongestants, as well as anti histamines , and nasal steroid sprays.his family history is significant for similar complaints in his 7 year old sister, and an aunt who is married for 15 years without children, and diagnosed with bronchiectasis, and had several episodes of hemoptysis. No elicit drugs used.He is Aa college student without significant environmental or occupational toxic exposure, he has no pets, and has not travelled outside of his home town since he was 15.On physical examination , he was afebrile, BP 127/ 76, HR 74, BMI 27, Oxygen saturation 96%.on room air, he was comfortable without respiratory distress, or chest deformities, he had left lower lobe crackles with faint end inspiratory wheezing, he had no clubbing, or cyanosis. His cardiovascular examination is within normal, he had no joint, eye, or skin changes.His laboratory work revealed mild elevation of CRP, and ESR. The rest of laboratory work was unremarkable. Both chest x-ray and HRCT of the chest showed bilateral lower lobe bronchiectasis, pulmonary function test revealed mild restrictive pattern. Semen analysis showed abnormal motility of sperms. CT of the sinuses showed opacification of the maxillary and ethmoid sinuses on the right. No airway biopsy was taken. The patient was counseled, and deferred to fertility clinic for further workup and education.

DISCUSSION: The classic symptom combination associated with PCD was first described by A. K. Zivert[11] in 1904, while Kartagener published his first report on the subject in 1933.This disease is genetically inherited. Structures that make up the cilia including inner and/or outer dynein arms, central apparatus, radial spokes, etc. are missing or dysfunctional and thus the axoneme structure lacks the ability to move.PCD is a genetically heterogeneous disorder affecting motile cilia[4] which are made up of approximately 250 proteins.[5] Around 90%[6] of individuals with PCD have ultrastructural defects affecting protein(s) in the outer and/or inner dynein arms which give cilia their motility, with roughly 38%[6] of these defects caused by mutations on two genes, DNAI1 and DNAH5, both of which code for proteins found in the ciliary outer dynein arm. Our patient did not have dextrocardia or total reversal of organs, but did have the evidence of chronic sinusitis and bronchiectatic changes, with a strong positive family history, which was very helpful in making the diagnosis of this rare condition.

CONCLUSIONS: This a case that demonstrates the importance of taking comprehensive history from patiens including family history in order to giagnose rare diseases which can help avoid many unnecessary tests and invasive diagnostic workup

1) Coren, Me; Meeks, M; Morrison, I; Buchdahl, Rm; Bush, A (2002). "Primary ciliary dyskinesia: age at diagnosis and symptom history. http://www.pcdsupport.org.uk/index.php/faqs/will_it_be_difficult_to_have_children/

2) Ceccaldi PF, Carre-Pigeon F, Youinou Y, Delepine B, Bryckaert PE, Harika G, Quereux C, Gaillard D. (2004). "Kartagener's syndrome and infertility: observation, diagnosis and treatment". J Gynecol Obstet Biol Reprod.

3) Chodhari, R; Mitchison, Hm; Meeks, M (March 2004). “Cilia, primary ciliary dyskinesia and molecular genetics”. Paediatric respiratory reviews

DISCLOSURE: The following authors have nothing to disclose: Islam Ibrahim

No Product/Research Disclosure Information

IMC, Jeddah, Saudi Arabia
Chest. 2012;142(4_MeetingAbstracts):19A. doi:10.1378/chest.1390047

SESSION TYPE: Airway Global Case Report Posters

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Bronchiolitis obliterans (BO) is disorder of the small airways, pathologically characterized by obliterative bronchiolitis with circumferential narrowing, ulceration, and scarring of the terminal and respiratory bronchioles. BO is characterized clinically by progressive dyspnea accompanied by dry cough. BO was first described in 1977 in 6 patients, 5 of whom had rheumatoid arthritis (RA).

CASE PRESENTATION: Female 77 years old, mild bronchiectasis, that required multiple ATB in last year's. She was stable receiving meprednisone 60 mg day and mycophenolate, that she left 6 months before. Spirometry showed mild obstruction (FEV1 1,2 liters about 60% of predicted). In the last 3 months dyspnea in progression appeared slowly with a severe obstruction with FEV1 0.3 liters No wheezes and only crackles. X ray normal. CT scan showed mosaic pattern of patchy regions of decreased lung attenuation that were accentuated on expiratory images. She had never received D-penicillamine, nor other drugs associated with BO. A diagnosis of steroid-resistant BO was made. Cyclophosphamide was given as adjunctive therapy, and a rapid improvement was seen. Until today she received 6 cycles of cyclophosphamide with a very important clinical and functional improvement. Now FEV1 is 0.8 liters.

DISCUSSION: BO is disorder of the small airways that generally has a poor prognosis, with inexorable progression and poor response to corticosteroids. On examination, inspiratory crackles and squeaks are heard. Pulmonary function tests (PFTs) show the rapid onset and progression of irreversible airflow limitation as demonstrated by a reduction in forced expiratory volume in 1 second (FEV1) and in the ratio of FEV1 to forced vital capacity (FVC). In addition, hyperinflation and air trapping may be present, although in later stages of disease, both restrictive and obstructive physiology due to the severity of the air trapping may be observed. HRCT may be more sensitive than PFTs for detecting small airways disease. The radiographic appearance is that of moderate to severe air trapping, as demonstrated by a mosaic pattern of patchy or segmental regions of decreased lung attenuation that are accentuated on expiratory images. At times, the clinical presentation and radiographic findings may be difficult to distinguish from those in chronic obstructive pulmonary disease (COPD), and may be accompanied by RA-ILD. The diagnosis of BO is usually made indirectly, using clinical, physiologic, and radiographic criteria. Other causes of small airways disease, such as significant tobacco use, should not be present. When surgical biopsy is obtained the pathologic appearance is fibrotic obliteration of the small airways, often accompanied by a lymphoplasmacytic infiltrate. The lesions tend to be patchy. Several reports suggested an association with both D-penicillamine and gold salts. In a recent series of 25 RA patients with BO, most with minimal or no smoking history, 48% had been treated with D-penicillamine, 40% with gold salts, 52% with methotrexate, and nearly all with corticosteroids. Of note, FEV1 was lower in patients who had ever received D-penicillamine than in those who had not. Other risk factors for BO include female sex and long-standing RA. BO generally has a poor prognosis, with inexorable progression and poor response to corticosteroids. However, response to treatment with corticosteroids and other immunosuppressive medications has been reported, so a trial of such therapy is often attempted.

CONCLUSIONS: In this case report of a patient with steroid resistant BO , Cyclophosphamide was given as adjunctive therapy, and a rapid improvement was seen. An early therapeutic trial of cyclophosphamide should be considered in patients with BO who fail to respond to steroids.

1) Purcell I.F. et al. Cyclophosphamide in severe steroid-resistant bronchiolitis obliterans organizing pneumonia. Respiratory Medicine Volume 91, Issue 3 , Pages 175-177, March 1997

DISCLOSURE: The following authors have nothing to disclose: Juan Enghelmayer, Hector Defranchi, Luis Marquez

No Product/Research Disclosure Information

Chest. 2012;142(4_MeetingAbstracts):20A. doi:10.1378/chest.1390647

SESSION TYPE: Airway Global Case Report Posters

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: It is well recognized worldwide that asthmatics have a poor perception of the severity of their bronchospasm. In the emergency management of Status Asthmaticus fluid resuscitation is of paramount importance, in addition to limiting the effects of dynamic hyperinflation in the mechanically ventilated patient. The contribution of endobronchial mucus to refractory bronchospasm must not be underestimated.

CASE PRESENTATION: A 35 year old male was referred to an urban teaching hospital from an outlying hospital for further management of Status Asthmaticus with Type 2 respiratory failure. The patient had presented to an outlying hospital earlier that day with a history of a non productive cough for four days, associated with SOB, and chest tightness. The day prior to presentation , his SOB worsened until he was barely able to complete sentences. He denied any fever. The patient was non compliant with his Ventolin and Beclomethasone inhalers. He failed to improve despite repeat nebulizations with Ventolin, IV steroids, and IV MgSo4. Within an hour of arrival at the referral hospital he has worsening respiratory distress, and requires intubation and ventilation. ABG on 10L O2 , pH = 7.355, pO2 =54.8mmHg,pCO2 = 79.9 mmHg, HCO3 = 30.3mmols/l SaO2 = 95.2%. .In the ICU overnight his hypercapnia persists despite paralysis, and controlled ventilation. Different ventilation strategies to reduce dynamic hyperinflation are used, but the patient demises within 8 hours of admission to the ICU. Autopsy showed voluminous lungs with no evidence of infection, no pneumothorax. There was extensive mucus plugging of the tracheobronchial tree.

DISCUSSION: The patient's lungs on histology showed no evidence of a pneumonia.This case highlights how much we underestimate the contribution of mucus plugging to refractory bronchospasm. We are reminded of the large amount of endobronchial mucus produced from the goblet cell hyperplasia in asthma. Fluid resuscitation is of paramount importance in the emergency management of Status Asthmaticus. Literature review as far back as 1977 in JAMA Vol 238, No.11, in a case series out of University of Colorado Medical Centre , showed extensive mucous plugging at the autopsies of patients who died from Status Asthmaticus.

CONCLUSIONS: Extensive endobronchial mucus can obstruct the traheobronchial tree and contribute to refractory bronchospasm in Status Asthmaticus. Careful fluid resuscitation is as important as reducing the complications of dynamic hyperinflation in the emergency management of these patients.

1) Scoggin Charles,Sahnn S., Status Asthmaticus A Nine -Year Experience JAMA Sept 12, 1977, Vol 238 No11 1158-1162 .

2) Mansel J.Keith, et al Mechanical Ventilation In Patients With Acute Severe Asthma American Journal of Medicine, Vol 89, July 1990 42-47

3) Leatherman James W., et al Effect of prolongation of expiratory time on dynamic hyperinflation in mechanically ventilated patients with severe asthma. Critical Care Medicine 2004, Vol.32 No.7 1542-1545

DISCLOSURE: The following authors have nothing to disclose: Althea Aquart-Stewart, May-Phyo Nyi Nyi

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University of the West Indies, Kingston, Jamaica
Chest. 2012;142(4_MeetingAbstracts):21A. doi:10.1378/chest.1363856

SESSION TYPE: Airway Student/Resident Case Report Posters

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Joint disease affecting adults with Cystic Fibrosis (CF) may present as episodic arthritis and/or hypertrophic pulmonary osteoarthropathy (HPOA). Gout is rarely reported in adults with CF. We report an adult CF patient who presented to us with Podagra.

CASE PRESENTATION: A thirty year old white man with CF presented with severe pain in left big toe and redness for one week. He denied trauma to left foot. There was no history of fever, infectious complications. Family history was insignificant for gout. He was prescribed Indomethacin by for seven days without relief. His exam showed red and swollen left first metatarsophalyngeal joint with excruciating pain on movement. His foot x rays showed mild hallux valgus with bunion formation without evidence of erosive periostitis. His serum uric acid level came elevated at ten mg/dl. He was diagnosed with classical podagra and started on Indomethacin followed by allopurinol with complete relief of his symptoms.

DISCUSSION: Arthropathy occurs in up to 12% of patients with CF and appears to be caused by immunologic processes. Acute episodes may affect all joints, are usually asymmetric, present with swollen, hot, red, and tender joints, often cause incapacitating pain, typically last seven to ten days, and usually are not erosive. Serologic analysis to exclude other causes of arthritis should be considered such as Gout which is rare. Joint fluid analysis is usually nonspecific and may be non inflammatory. Non-steroidals and steroidals anti-inflammatory medications are used in management of CF arthritis. HPOA is characterized by chronic, proliferative long-bone periostitis, causing symmetrical bone pain and painful oligosynovitis in the large joints.Unlike arthritis, HPOA exacerbations tend to accompany pulmonary infectious exacerbations. Ourpatient had classic findings of Podagra, elevated serum urate and response to appropriate therapy. It is a hypothesis that pancreatic enzyme supplements which contain high levels of purine may be responsible for hyperuricemia in adult CF patients.

CONCLUSIONS: Surviellance of serum urate is not routinely performed but consideration should be given to adding this to investigations. Review of pancreatic enzyme intake in those with confirmed gout or extreme hyperuricemia can be considered.

1) Gout and hyperuricaemia in adults with cystic fibrosis. Horsley A, Helm J, Brennan A, Bright-Thomas R, Webb K, Jones A.Manchester Adult Cystic Fibrosis Centre, Wythenshawe Hospital, Manchester, UK. J R Soc Med. 2011 Jul;104 Suppl 1:S36-9.

2) Cystic Fibrosis Adult Care. Consensus Conference Report. ( Chest 2004; 125: 1S-39S)

3) Schidlow DV, Goldsmith DP, Palmer J, et al. Arthritis in cystic Fibrosis. Arch Dis of child 1984; 59:377-379

DISCLOSURE: The following authors have nothing to disclose: Sumaira Malik, Nauman Chaudary

No Product/Research Disclosure Information

UMC, Brandon, MS
Chest. 2012;142(4_MeetingAbstracts):22A. doi:10.1378/chest.1383053

SESSION TYPE: Airway Student/Resident Case Report Posters

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Granulomatosis with polyangiitis (GPA or Wegener’s) is a form of antineutrophil cytoplasmic antibody (ANCA) - associated vasculitis. It is far more common in older adults with racial predominance among the white population. We report the case of a 29-year-old African American male diagnosed with GPA following recurrent hemoptysis and treatment for recurrent pneumonia.

CASE PRESENTATION: A 29-year-old African American male with no past medical history presented with a 2 month history of several bouts of cough, occasionally productive of yellowish sputum, hemoptysis, and nasal congestion. He also reported subjective fevers, dyspnea on exertion, fatigue and a 23 pound unintentional weight loss. The patient was tachypneic (RR: 24), tachycardic (HR: 122) and hypertensive (BP: 184/73) on initial evaluation. His laboratory studies revealed leukocytosis (WBC: 17,200) with a left shift (Neutrophil count: 91%), anemia (Hb/Hct: 7.2/25.5), thrombocytosis (Platelet count: 899,000) and normal renal indices with trace blood on urinalysis. The patient had been treated symptomatically on several occasions for respiratory tract infection without resolution. Chest radiography revealed diffuse cavitary lesions with air-fluid levels. The patient was admitted to a negative pressure room and initiated on broad-spectrum antibiotics with concern for tuberculosis. Tuberculosis was ruled out; however, his C-ANCA (PR-3) test came back positive (59.96 EU/mL, normal is < 4), suggestive of vasculitis. The patient underwent intranasal biopsy which revealed acute necrotizing inflammation with vasculitis diagnostic of GPA. Induction therapy with intravenous methylprednisone and cyclophosphamide was initiated. The patient improved symptomatically and the hemoptysis resolved. However, after discharge he had a relapse of hemoptysis requiring hospitalization and an increase in cyclophosphamide dosing.

DISCUSSION: This case illustrates the uncommon occurrence of GPA in a young African American adult. Symptoms of GPA overlap a variety of cardiopulmonary diseases including; pneumonia, tuberculosis, heart failure and fungal infections. Cavitary lung lesions are a known feature of this disease and should prompt clinicians to include GPA in their differential diagnosis. Screening tests such as the ANCAs are valuable but a biopsy showing vasculitis is the gold standard for detection. Treatment is most effective when given early and with a combination of immunosuppressive agents.

CONCLUSIONS: The evaluation of patients with any of the following symptoms: recurrent respiratory tract infections, hemoptysis, and cavitary lung lesions has a broad differential diagnosis that must include ANCA associated vasculitis. Once recognized, this disease is treatable though outcomes and levels of success do vary.

1) Hoffman GS, Kerr GS, Leavitt RY, et al. Wegener granulomatosis: an analysis of 158 patients. Ann Intern Med 1992; 116:488.

DISCLOSURE: The following authors have nothing to disclose: Amaka Ezimora, Oluwafisayo Adebiyi, Taopheeq Mustapha, Jason Martin

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Meharry Medical College, Nashville, TN
Chest. 2012;142(4_MeetingAbstracts):23A. doi:10.1378/chest.1390716

SESSION TYPE: Airway Student/Resident Case Report Posters

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: We present a case of asthma exacerbation resistant to conventional medical management

CASE PRESENTATION: A 74-year-old female recently diagnosed with asthma by her primary care provider presented to our hospital with progressively worsening shortness of breath. She had been having flu-like illness for the past week. Patient was on inhaled bronchodilators at home but her asthma was never “well-controlled”. Chest radiograph in the ED showed a complete white-out of the right lung (Fig. 1) . Computerized tomography (CT) of the chest showed atelectatic right lung with loculated effusion (Fig. 2). Despite chest tube and broad spectrum antibiotics her condition did not improve. A repeat CT scan showed obstruction in right lower lobe. Consequent flexible bronchoscopy performed to evaluate for an endobronchial tumor, revealed a foreign body (Fig. 1) in the distal portion of the right bronchus intermedius. The foreign body was retrieved after multiple attempts and laser removal of the granulation tissue. The patient was extubated soon after. On discussing the findings with the family, the daughter mentioned that the patient did choke on a piece of chicken two years ago. Not surprisingly, she was diagnosed with asthma a few months later.

DISCUSSION: Tracheobronchial obstruction by a foreign body was first discovered as a cause of wheezing by Struthers in 1852. In adults, food products like vegetables, peanuts and bones are the usual offending agents. Foreign bodies often lodge at the carina or the right mainstem bronchus due to the anatomy of the airways. Stridor and localized wheezing occur due to turbulent airflow around the narrowed airway, however, irritation of the airway causing bronchospasm can produce generalized wheezing, indistinguishable from asthma. Foreign body aspiration in adults is more common in the setting of alcohol use, poor dentition, underlying neurologic disease and advanced age. Flexible bronchoscopy is successful at removing 60-90% of foreign bodies, but rigid bronchoscopy should be used in retrieval of objects too large to grasp firmly via the flexible fiberoptic scope.

CONCLUSIONS: Not all wheeze is asthma and a comprehensive history is often instrumental in making an early diagnosis of foreign body aspiration.

1) Thomas, PS, Geddes, DM, Barnes, PJ. Pseudo-steroid resistant asthma. Thorax 1999; 54,352-356.

2) Zaas, D, Brock, M, Yang, S. An uncommon mimic of an acute asthma exacerbation. Chest 2002; 121:1707-1709.

3) Ferrer, M, Ferrer, A, Marin, A. Removal of a large endobronchial foreign body with a fiberoptic bronchoscope. Respiration 1991; 58,231-232.

DISCLOSURE: The following authors have nothing to disclose: Kriti Lonial, Anuja Vyas

No Product/Research Disclosure Information

Topics: asthma , symptom onset
Chest. 2012;142(4_MeetingAbstracts):24A. doi:10.1378/chest.1380786

SESSION TYPE: Airway Student/Resident Case Report Posters

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: The negative pressure pulmonary edema (NPPE) is a known cause of acute respiratory failure requiring mechanical ventilation and supportive care. This is most often seen in post surgical and post general anesthesia patients. Here, we report a case of laryngeal asthma presenting as NPPE.

CASE PRESENTATION: 29 year old female with a history of anxiety and depression presents with shortness of breath for four days with no other symptoms. She has 5 pack year history of smoking. On admission, body temperature was 37.2 C, blood pressure was 150/107 mm Hg and pulse 120. She had tachypnea, expiratory wheezing and occasional stridor. CBC, BMP and ABG are normal. Urine drug screen shows cocaine and Benzodiazepine. Twenty minutes later she had respiratory distress and was found unresponsive. On physical exam, she had diffuse bilateral crackles. Direct laryngoscopy showed inspiratory adduction of anterior 2/3 of vocal cords. She was intubated for airway protection. Chest xray revealed bilateral diffuse patchy interstitial infiltrates. 2D ECHO reveals ejection fraction of 60% with normal findings. Bronchoscopy and CT neck were normal. She gradually improved and extubated successfully after 48 hours.

DISCUSSION: We suspect NPPE as the cause of this patient’s acute respiratory failure. The bilateral diffuse pulmonary infiltrates and rapid resolution are compatible with diagnosis of NPPE, making aspiration pneumonitis less likely. Most common recognized cause of NPPE is emergence from general anesthesia and post-operative extubation. We hypothesize that laryngeal asthma in this patient precipitated NPPE. Laryngeal asthma aka vocal cord dysfunction is the abnormal adduction of true vocal cords during inspiration or expiration, and is seen in female patients with various psychiatric disorders including depression/anxiety. Many are often misdiagnosed as asthma. Diagnosis is by direct laryngoscopic visualization of inspiratory adduction of anterior 2/3 of vocal cords. They usually have normal ABG, PFT’s (except the inspiratory limb of the Flow-volume loop) and negative bronchoprovocation testing.

CONCLUSIONS: The question remains, can laryngeal asthma generate enough negative intrathoracic pressure to cause NPPE and acute respiratory failure? In theory it would be similar mechanism to laryngeal spasm with closure of central airway and inspiratory efforts against a closed glottis creating large negative intra pleural and alveolar pressure.

1) DJ Krodel, EA Bittner, REE Abdulnour Negative Pressure Pulmonary Edema Following Bronchospasm Chest November 2011 vol. 140 (5) 1351-1354

2) Kent NJ, Howard DA, Raby RB, Lew B, Blaiss M. Airway Fluoroscopic Diagnosis of Vocal Cord Dysfunction Syndrome. Annals of Allergy, Asthma & Immunology. 78:6. June 1997: 586-588.

3) Morris MJ, Kent CL. Diagnostic Criteria for the Classification of Vocal Cord Dysfunction. Chest. 2010 Nov; 138 (5): 1213-1223

DISCLOSURE: The following authors have nothing to disclose: Prasanna Tadi, Arpana Mahalingashetty, Gary Wendell

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Crozer Chester Medical Center, Upland, PA
Chest. 2012;142(4_MeetingAbstracts):25A. doi:10.1378/chest.1382938

SESSION TYPE: Airway Student/Resident Case Report Posters

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Extranodal laryngeal lymphomas are exceedingly rare, with less than 100 cases described in literature.#3We present a case encountered in clinical practice.

CASE PRESENTATION: A 56 y/o non smoking Caucasian male with history of Hashimoto’s thyroiditis, coronary artery disease with multiple coronary stent procedures, presented with a 6 weeks of hemoptysis, voice hoarseness, dysphagia and foreign body sensation in throat. Labs showed microcytic hypochromic anemia and markedly elevated TSH levels. CT scan of the chest did not reveal any focal infiltrates or masses. An echocardiogram confirmed an EF of 15-20% with global hypokinesis. Direct laryngoscopy did not demonstrate a supraglottic lesion. Flexible fiberoptic bronchoscopy revealed a circumferential submucosal, subglottic mass protruding into the lumen with partial airway obstruction.No other endobronchial lesions were appreciated. Endobronchial biopsies, although suspicious for squamous cell carcinoma, did not immunostain with neuroendocrine or squamous markers but were positive for CD20 and HLA markers, confirming the diagnosis of diffuse large B cell lymphoma with aggressive features. A PET scan confirmed only laryngeal involvement. The patient subsequently underwent tracheostomy followed by chemotherapy with R-CVP. Doxorubicin was held because of his history of ischemic cardiomyopathy and recommendations made for consolidative radiation therapy. PET/CT scan post chemotherapy showed complete resolution of the subglottic mass.

DISCUSSION: Differential diagnoses for this patient included thyroid lymphoma given his history of Hashimotos thyroiditis. Extranodal NHL of larynx account for less then 1% of laryngeal neoplasms.#3.Symptomatology includes, hoarseness, dysphagia, dysphonia, cough, haemoptysis, forgein body sensation and stridor. Diagnosis is by biopsy, immunohistostaining and flow cytometry. If required, airway should be secured followed by definitive management with chemotherapy or radiation. Resection as in most other cases of submucosal laryngeal lesions, is relatively contraindicated, unless sever airway obstruction encountered on diagnosis.

CONCLUSIONS: Malignant laryngeal lymphomas are a rare cause of airway compromise, however they should be considered among differentials, as management is different from other laryngeal lesions. Radiation and chemotherapy are most commonly advocated therapies for laryngeal lymphomas worldwide.#2

1) Ansell SM,Habermann TM, Hoyer JD, Strickler JG, Chen MG, Mc Donald TJ:Primary laryngeal lymphoma:The Laryngoscope 107:November1997

2) Rosenthal EL;Primary laryngeal lymphoma:reoprt of 3 cases and review of literature;Head and Neck-DOI April 2010

3) Word R, Urquhart AC, Ejercito VS:Primary laryngeal lymphoma:case report:ENT-Ear,Nose and Throat Journal:Volume 85 ,Number 2,Febuary 2006.

DISCLOSURE: The following authors have nothing to disclose: Nirav Patel, Kala Davis-McDonald

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St. Agnes Hospital, Baltimore, MD
Topics: lymphoma , larynx
Chest. 2012;142(4_MeetingAbstracts):26A. doi:10.1378/chest.1390925

SESSION TYPE: Airway Student/Resident Case Report Posters

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Foreign body aspirations, although more common amongst children and the elderly, can lead to severe infections.

CASE PRESENTATION: A 33 year old male with no known past medical history presented with a 3 month history of fatigue, episodic fevers, and cough with productive sputum. Patient was seen in a walk in clinic at the onset of symptoms and was told that he had a bronchitis and he was prescribed a 5 day course of azithromycin which did not resolve his symptoms. He denied any weight loss or other constitutional symptoms. Also he denied having any recent sick contacts. Furthermore he had a recent HIV test which was negative. On admission, the patient was febrile to 39.2°C, BP 90/56, HR 120, RR 26, 91% on 2L NC. Exam was significant for tachycardia, decreased breath sounds on the right lung base as compared to the left, and diaphoresis. Labs was significant for a wbc count of 39 K/mcL. Otherwise unrevealing. An XR of the chest revealed foreign body aspiration in the right intermediate bronchus with superimposed pneumonia. Upon further questioning, it was illicited that the patient was involved in an altercation where he presumably lost his imitation gold teeth cover. The patient was started on broad spectrum Vancomycin and Zosyn. He continued to remain hypotensive and febrile despite broad antibiotic coverage. Interventional pulmonology was consulted. A bronchoscopy was performed with retrieval of the foreign object. The retrieval of the object was complicated by formation of granulation teeth; however it was finally able to be retrieved. Given the extent of granulation tissue, the patient underwent a significant amount of laser ablation of lung tissue. Over the next few days, the patient deferversed and improved clinically.

DISCUSSION: Foreign body in the bronchus can present with variable symptoms depending on the severity. These can range from nonspecific respiratory complaints to long-term irreversible damage. Prompt recognition of the aspiration of the foreign body is important to identify as inflammatory granulation can develop as occurred with our patient.

CONCLUSIONS: Foreign body aspiration can lead to severe infections. Prompt recognition is essential to prevent the sequelae of inflammatory granulation.

1) Takenaka, M, et al. Management of patients with bronchial foreign bodies. Journal of UOEH 2011; 33(2),157-61.

DISCLOSURE: The following authors have nothing to disclose: Aalok Patel, Edwin Nunnery, Bhavin Adhyaru

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Emory University School of Medicine, Atlanta, GA
Chest. 2012;142(4_MeetingAbstracts):27A. doi:10.1378/chest.1381182

SESSION TYPE: Airway Student/Resident Case Report Posters

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Endobronchial lipoma is an extremely rare benign pulmonary tumor. Different patients with endobrochial lipomas have varieties of clinical symptoms. Nowadays, therapeutic bronchoscopy have been replacing conventional surgery for the treatment of it.

CASE PRESENTATION: A 67-year-old man presented with cough and sputum for 2 months. A chest CT demonstrated atelectasis of the left up lobe, hydrothorax in the left thoracic cavity, and stenosis of the left up bronchus. Bronchoscopy showed a well defined, smooth tumor at the beginning of the right up bronchus(fig.1). APC resection was performed by endoscopy with no complications. Pathology confirmed the diagnosis of Endobronchial Lipoma (fig.2). Carbenin was then used for 20d. The patient was discharged 20d after admission and has been followed up for 2 year without symptoms. The chest CT (2 months late) showed that the sighs have been better.

DISCUSSION: Endobronchial lipomas originate from the adipose tissue that is normally present in the tracheobronchial wall, accounting for only 0.1% to 0.5% of all lung tumors. Depending on the location of the tumor, and the severity of bronchial obstruction, endobronchial lipomas present varieties of symptoms, including persistent cough, sputum, dyspnea, recurrent pneumonia, or even no symptoms. A large number of people had abnormal chest radiographic findings. The most common radiographic manifestation is atelectasis, obstructive pneumonia, and so on. Bronchoscopy can directly show the tumor, and transbronchial lung biopsy can final diagnosis the disease, although, because of the the submucosal growth of endobronchial lipomas, their detection rates are rather low. Nowadays, bronchoscopic resection has been considered as the first choice of treatment for bronchial lipoma. But there are still some limitations: First, there are some difficulties in obtaining the definitive diagnosis. Second, long-term atelectasis or pneumonia will also lead to some peripheral destructive lung diseases. Finally, there are technical problems in the treatment of completely obstructive endobronchial benign tumor.

CONCLUSIONS: Edobronchial lipomas are extremely rare lung benign tumors; they have varieties of symptoms, especially cough and atelectasis; chest radiographical examinations are chief diagnostic methods; bronchoscopy can not only be a diagnostic method, but also be a therapeutic method; using APC resection through bronchoscopic to remove the lipoma is a very efficacious therapeutic method.

1) Masashi M, Tadayuki O, Shinji A, Takeshi N, Masachika I, Naofumi S, et al. Endobronchial lipoma. Review of 64 cases reported in Japan. Chest. 2003;123:293-6.

2) MacArthur CGC, Cheung DLC, Spiro SG: Endobronchial lipoma: A review with four cases. Br J Dis Chest 71 :93-100,1977

DISCLOSURE: The following authors have nothing to disclose: Fanglei Liu, Enguo Chen, Kejing Ying

No Product/Research Disclosure Information

Zhongshan Hospital Affiliated to Fudan University, Shanghai, China
Topics: lipoma
Chest. 2012;142(4_MeetingAbstracts):28A. doi:10.1378/chest.1389648

SESSION TYPE: Airway Student/Resident Case Report Posters

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Mounier-Kuhn’s syndrome is a rare congenital abnormality characterized by recurrent infections and productive cough. Often times it presents similarly to more common pulmonary disorders such as chronic obstructive pulmonary disease (COPD) and asthma, and the diagnosis may be missed. We report a case of Mounier-Kuhn syndrome or Tracheobronchomegaly in an ex-smoker thought to have COPD, but further work-up revealed otherwise.

CASE PRESENTATION: This is a case report of 60 years-old male who presented to the pulmonary clinic for difficult to treat COPD. He had been seen by his primary care physician for COPD and stated that he had minimal improvement in symptoms with conventional COPD therapy. He had been hospitalized several times for COPD exacerbations without significant findings on plain film chest x-ray. Patient has a 30 pack year smoking history and had quit 20 years ago. He is not actively smoking. Physical exam showed mild digital clubbing, but otherwise unremarkable. Spirometry showed and FEV1/FVC ratio of 80% and an FEV1 of 2.57 Liters (97%) and computed tomography (CT) showed tracheobronchomegaly with the trachea measuring 49.2 mm in largest diameter, collapsed middle lobe and right middle lobe bronchus.

DISCUSSION: Mounier-Kuhn’s syndrome is an uncommon pulmonary disorder caused of Tracheobrochomegaly and dilation of the tracheobronchial tree. The larger trachea can lead to mucus collection in the airways resulting airways collapse and chronic infection. The etiology of Mouner-Kuhn’s disease is unknown and dilation is due to atrophy of the muscular and elastic tissues and it is more common in men in the 3rd and 4th decades of life. It is unclear at this time is smoking exacerbates the disease. Diagnosis is made by CT and treatment is mainly supportive. Clinically, patients may present with cough and recurrent lung infections similarly to COPD.

CONCLUSIONS: This patient was diagnosed with COPD secondary to his clinical history of smoking, and not necessarily his spirometry or CT findings. A strong index of suspicion may have prompted a CT scan earlier in his clinical presentation and an earlier diagnosis.

1) Prakash UB. Uncommon causes of cough: ACCP evidenced-based clinical practice guidelines. Chest 2006; 129 (1 Suppl): 206s-219s.

2) Menon B, Aggarwal B, Igbal A. Mounier-Kuhn Syndrome: report of 8 cases of tracheobronchomegaly with associated complications. South Med J 2008; 101(1): 83-87.

3) Celik B, Bilgin S, Yuksel C. Mounier-Kuhn syndrome: a rare cause of bronchial dilation. Tex Heart Inst J 2011: 30(2): 194-196.

DISCLOSURE: The following authors have nothing to disclose: Nayle Araguez Ancares, Noeen Ahmad, Pablo Loarte, Say Salomon, Yanely Pineiro-Puebla

No Product/Research Disclosure Information

Woodhull Medical Center, Brooklyn, NY
Topics: cough
Chest. 2012;142(4_MeetingAbstracts):29A. doi:10.1378/chest.1378365


PRESENTED ON: Tuesday, October 23, 2012 at 11:15 AM - 12:30 PM

INTRODUCTION: Obstructive sleep apnea (OSA) is often associated with obesity. Infrequently in adults, isolated lesions of the upper airways can produce OSA [1]. We report a post-transplant patient with tonsillar lymphoma and OSA.

CASE PRESENTATION: A 45 year old man with history of kidney transplant, hypertension and hyperlipidemia presented with 6 months history of loud snoring, daytime hypersomnolence and recurrent sore throat. He had undergone kidney transplant 18 months prior and reported progressive weight gain since then. His BMI was 30.7 and neck circumference was 43 cm. Examination of the oropharynx revealed grade 4 tonsillar enlargement. Epworth Sleepiness score was 19. His AHI was 59.1/hr and CPAP therapy was initiated. In view of the marked tonsillar enlargement he was subjected for tonsillectomy and uvulopharyngoplasty. Postoperative histopathology showed a low grade B cell Lymphoma. EBV IgG serology was positive. Bone marrow studies were negative for malignant lymphoma. CT Thorax and Abdomen was normal. Chemotherapy was not started and the lymphoma remained in remission at one year follow-up. A repeat PSG 6 months after surgery showed a residual AHI of 25/hr and patient was continued on CPAP therapy.

DISCUSSION: Upper airway obstruction due to tonsillar hypertrophy superimposed on a narrow oropharynx had produced increasing symptoms in this patient. Surgery improved the apnoeic episodes by 42% however post-surgical AHI of 25/hr suggests a multifactorial cause of OSA. This case of tonsilar lymphoma presenting as OSA in a typical patient description emphasizes the importance of a careful clinical examination of the upper airway in patients with features of sleep apnea. This patient has post-transplant lymphoproliferative disorder (PTLD). PTLD is a well known complication of solid organ transplantation however isolated tonsillar PTLD in the adult population is rare [2]. PTLD is often associated with Epstein-Barr virus infection as evident in this patient. Reduction in immunosupression is often sufficient for treatment [3].

CONCLUSIONS: This case highlights the importance of clinical upper airway assessment in the evaluation of patients with OSA. Even when the patient’s body habitus is typical, upper airway pathology can still be a contributing factor to the occurrence of OSA.

1) Feldman BS, Quan SF. Tonsillar lymphoma as a cause of obstructive sleep apnea .Sleep Med.2002;5:441-2.

2) Williams MD, Brown HM. The adequacy of gross pathological examination of routine tonsils and adenoids in patients 21 years old and youger. Human Pathology.2003;10:1053-7.

3) Rami T. Bustami et al. Immunosuppression and the Risk of Post-Transplant Malignancy Among Cadaveric First Kidney Transplant Recipients. American Journal of Transplantation. 2004;1.

DISCLOSURE: The following authors have nothing to disclose: Lalitha Pereirasamy, Ong Thun How

No Product/Research Disclosure Information

Department of Respiratory Medicine, Penang General Hospital, Georgetown, Malaysia
Chest. 2012;142(4_MeetingAbstracts):30A. doi:10.1378/chest.1382329


PRESENTED ON: Tuesday, October 23, 2012 at 11:15 AM - 12:30 PM

INTRODUCTION: Aorto-bronchial fistulae secondary to thoracic aortic repair has only been reported fifteen times in literature. Massive hemoptysis can occur and prompt recognition of a fistula improves survival.

CASE PRESENTATION: An 88 year old man with history of hypertension and a thoracic aorta aneurysm, repaired with a surgical graft placement 7 years earlier, presented to the hospital with massive hemoptysis. Chest X rays and computerized tomography (CT) showed no lesion on parenchyma. He underwent a bronchoscopy that showed only blood clots in the left main bronchus but no active source of bleeding was identified. His hemoptysis resolved and he was sent home without a specific diagnosis. A week later he returned with recurrent episodes of hemoptysis producing up to 300 milliliters of blood. Chest CT with aneurysm protocol was done showing a subtle air tract coming from the superior segment of left lower lobe (Figure 1) and extravasation of contrast coming from thoracic aorta (Figure 2) suggestive of aorto-bronchial fistulae. The patient was taken for a thoracic endovascular aortic repair (TEVAR) which confirmed the diagnosis and corrected his hemoptysis.

DISCUSSION: Aorto-bronchial fistulae were first described secondary to infections such as tuberculosis and fungi. In 1934 such fistulae were described post-mortem in patients with aneurysm of the descending thoracic aorta. Infection or close contact between the vessel and the bronchial wall causes an inflammatory response that produces a connection between structures. In our case it appears that the prior aneurysm graft repair triggered the fistula formation. Published data about the benefits between open surgery repair versus endovascular intervention for aorto-bronchial fistulae is lacking. Comparison between both procedures is well known in thoracic aortic aneurysm repair, which reports better lower 30 day mortality rate and stroke incidence in patients who undergo endovascular grafts compared to open surgery. In our case patient underwent successful endovascular grafting because of high risk of post-procedure complications.

CONCLUSIONS: Massive hemoptysis secondary to aorto-bronchial fistulas in patients with history of thoracic aorta aneurysm repair has to be always considered and endovascular grafting is a reasonable intervention that may decrease post-operative complications.

1) MacIntosh EL, Parrott JC, Unruh HW. Fistulas between the aorta and tracheobronchial tree. Ann Thorac Surg. 1991 Mar;51(3):515-9.

2) Kazerooni EA, Williams DM, Abrams GD, Deeb GM, Weg JG. Aortobronchial fistula 13 years following repair of aortic transection. Chest. 1994 Nov;106(5):1590-4.

3) Jonker FH, Verhagen HJ, Lin PH, Heijmen RH, Trimarchi S, Lee WA, Moll FL, Atamneh H, Rampoldi V, Muhs BE. Open surgery versus endovascular repair of ruptured thoracic aortic aneurysms. J Vasc Surg. 2011 May;53(5):1210-6. Epub 2011 Feb 5.

DISCLOSURE: The following authors have nothing to disclose: Hiram Rivas-Perez, Mark Wewers

No Product/Research Disclosure Information

Ohio State University, Columbus, OH
Topics: aortic aneurysm
Chest. 2012;142(4_MeetingAbstracts):31A. doi:10.1378/chest.1387137


PRESENTED ON: Tuesday, October 23, 2012 at 11:15 AM - 12:30 PM

INTRODUCTION: Vocal Cord Dysfunction (VCD) usually presents with dyspnea, often mistaken for severe asthma attacks. This case describes postoperative respiratory failure with negative pressure pulmonary edema in a patient with history of VCD. To our knowledge this is the first case of negative pressure pulmonary edema associated with VCD.

CASE PRESENTATION: A 41 year-old white female patient with history of anxiety disorder and Vocal Cord Dysfunction diagnosed by direct laryngoscopy. She has history of multiple emergency room visits with asthma-like attacks. Otolaryngologist evaluation for hoarseness confirmed the diagnosis of VCD, but also revealed a nodule in her left thyroid. Ultrasound of her thyroid gland showed a 3 centimeter nodule in her left thyroid lobe. Aspirate of the nodule was suspicious for papillary cancer and the patient was referred for thyroidectomy. The patient had an uneventful surgery, no complications noted during intubation. The procedure lasted 3 hours and she did not require blood transfusion. Immediately after postoperative extubation, she went into severe distress with associated stridor/hypoxemia and required reintubation. The patient’s chest x-ray revealed bilateral parenchymal densities. We suspected negative pressure pulmonary edema. The patient had a normal electrocardiogram and echocardiography. She was kept on assisted-controlled mechanical ventilation with lung protective strategy. We did not use diuretics, antibiotics or corticosteroids. The patient achieved excellent recovery over the next 2 days. Thyroid pathology was consistent with Hashimoto's thyroiditis.

DISCUSSION: Postoperative Pulmonary Edema usually results from laryngospasm with sustained vocal cord adduction. It is thought that this condition results from forced inspiration against closed upper airways. High negative intrathoracic pressure will shift capillary interstitial fluid inward via increase in hydrostatic pressure. This will result in pulmonary edema. Unlike cardiogenic edema, patients with Negative Pressure Pulmonary Edema (NPPE) have normal cardiac filling pressures. Also, they have rapid radiological resolution and clinical recovery compared to patients with aspiration. Postoperative laryngospasm is a potentially life threatening condition. It is imperative to immediately improve oxygenation and reestablish airways. Management of respiratory failure secondary to NPPE includes supportive care. Low tidal volumes or lung protective strategy seems appropriate. Diuretics are not beneficial and antibiotics are not indicated. It is recommended to obtain an echocardiogram.

CONCLUSIONS: The occurrence of high negative pressure during laryngospasm may be exaggerated in patients with chronic VCD. We recommend careful postoperative monitoring for patients with VCD.

1) Pulmonary edema due to upper airway obstruction in adults. Willms D;Shure D. Chest 1988 Nov;94(5):1090-2

DISCLOSURE: The following authors have nothing to disclose: Souheil Abdel Nour, Ty Slatton, Ryland Byrd, Thomas Roy

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East Tennessee State University, Johnson City, TN
Chest. 2012;142(4_MeetingAbstracts):32A. doi:10.1378/chest.1366486


PRESENTED ON: Tuesday, October 23, 2012 at 11:15 AM - 12:30 PM

INTRODUCTION: Tracheoesophageal fistula (TEF) is a complication of malignancies of the esophagus and airway and its treatment. We describe a case of esophageal cancer with esophageal stent erosion into the trachea.

CASE PRESENTATION: A 68 year-old female was diagnosed with esophageal stricture due to a squamous cell carcinoma of the upper esophagus which was deemed unresectable. She underwent placement of an uncovered esophageal self-expanding metal stent (SEMS) for palliation and symptom control. Subsequently, she underwent chemotherapy and radiation therapy, in addition to having a PEG tube placed. Few months later, the patient developed progressive productive cough associated with oral intake, and recurrent aspiration pneumonias for which she was then evaluated at our institution. She underwent a chest CT which revealed a possible defect/TEF located at the proximal portion of the esophageal stent. Barium swallow showed a small amount of contrast in the left main stem bronchus consistent with aspiration versus TEF. Upper endoscopy revealed epithelialization of the stent into the esophagus, but no obvious evidence of TEF or tumor recurrence. Argon plasma coagulation was used to treat a narrowing at the distal portion of the stent and biopsies taken from this area were consistent with granulation tissue. Subsequently, rigid bronchoscopy showed large posterior tracheal wall erosion with exposure of the uncovered esophageal stent into the trachea. Surgical closure was not considered feasible and the decision was made to proceed with parallel covered tracheal and esophageal stenting. A covered tracheal metal stent (20x60 mm) was placed and was externally fixed to the neck using a button. Repeat upper endoscopy was performed and a fully covered esophageal stent (23x100 mm) was placed into the existing uncovered SEMS. Follow-up barium swallow study did not reveal any evidence of fistula or aspiration, and her productive cough significantly improved.

DISCUSSION: Self-expanding esophageal stents are commonly used to palliate malignant esophageal strictures. Their placement can be complicated by the development of a TEF due to erosion into the posterior tracheal wall. Patients often develop persistent coughing and recurrent aspiration pneumonia. Our patient is thought to have developed a TEF/erosion from the combination of mechanical pressure of the stent and radiation therapy, rather than direct malignant invasion. Stenting of the trachea and covered esophageal stent placement within the existing uncovered stent resulted in the sealing of the defect and resolution of aspiration.

CONCLUSIONS: Surgical repair of TEF is associated with relatively high morbidity and mortality, and endoscopic approach with parallel placement of covered esophageal and tracheal stents is considered to be the first line therapy.

1) Herth FJ, et al. Combined airway and esophageal stenting in malignant airway-esophageal fistulas: a prospective study. Eur Respir J. 2010 Dec;36(6):1370-4.

DISCLOSURE: The following authors have nothing to disclose: Ali Khodabandeh, Ryan Chua, Ali Ashraf, Hisashi Tsukada, Bhavesh Shah, Samaan Rafeq

No Product/Research Disclosure Information

Division of Pulmonary, Critical Care, and Sleep Medicine, St. Elizabeth’s Medical Center, Tufts University School of Medicine, Boston, MA

Cardiothoracic Surgery

Chest. 2012;142(4_MeetingAbstracts):33A. doi:10.1378/chest.1390578

SESSION TYPE: Thoracic Surgery I

PRESENTED ON: Monday, October 22, 2012 at 11:15 AM - 12:30 PM

PURPOSE: The National Emphysema Treatment Trial established the efficacy of LVRS and defined the target patient population. Now, a decade since accrual for this landmark trial ended, the volume of LVRS performed in the United States remains remarkably low. LVRS is limited to JCHO certified sites and approved lung transplant centers which may reduce utilization but ensures rigorous monitoring of outcomes of the procedure. We reviewed the Society for Thoracic Surgery (STS) database from the year of publication of the NETT to the present to assess utilization and outcomes of the procedure.

METHODS: The general thoracic STS database was queried, identifying all patients undergoing LVRS between 2003 and 2011. Volume of procedures was assessed annually. Demographics and comorbidities were recorded. Primary outcomes evaluated were length of stay (LOS) and mortality. Secondary outcome was morbidity. Complications were recorded based on existing STS definitions. Quantitative data was recorded as mean, median, 25th and 75th quartiles.

RESULTS: A total of 585 LVRS patients were identified over a 9 year period. Yearly distribution ranged from 20-118, annual average 65 cases. Mean age was 61 (median 62), 90% were Caucasian, 45% female. Preoperative mean and median FEV1(% predicted) were 31 and 28 respectively. Mean DLCO was 37% predicted. Mean pack/year smoking history was 56 years and median 50. Morbidity was documented in 72% of patients. Pulmonary complications were numerous with prolonged air leak (60%) most common. Atrial arrhythmia (14%) was the most common non-respiratory complication. Prolonged ventilation occurred in 2.9% of patients and 6% had unexpected return to ICU. Postoperative LOS was mean 11 days and median 9 days. Mortality at discharge was 5.98% and 30-day mortality 4.79%

CONCLUSIONS: STS database review confirms that though LVRS volume has increased modestly since the initial NETT data was published in NEJM; it remains an underutilized therapy for patients with severe emphysema. Patient demographics, comorbidities and physiologic parameters (FEV1, DLCO) suggest that when utilized appropriate candidates are selected. Morbidity remains high for this procedure and mortality is similar to that seen in the non-high risk candidates identified in the NETT.

CLINICAL IMPLICATIONS: LVRS volume has increased slowly and is less than expected given the prevalence of emphysema. Database review can assist in identifying trends in utilization as well as best practice information to optimize outcomes.

DISCLOSURE: The following authors have nothing to disclose: James Maloney, Nicole Strieter, Jeffrey Havlena

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University of Wisconsin, Madison, WI
Chest. 2012;142(4_MeetingAbstracts):34A. doi:10.1378/chest.1388185

SESSION TYPE: Thoracic Surgery I

PRESENTED ON: Monday, October 22, 2012 at 11:15 AM - 12:30 PM

PURPOSE: We report our experiences with a previously described, but underutilized, technique for minimally invasive localization and surgical excision biopsy of small lung nodules—micro-coil guided video-assisted thoracoscopic (MC-VATS) lung resection. Accurate diagnosis of small intrapulmonary lung nodules (0.5-2.0 cm) is a challenge. It can be difficult to reliably biopsy these under CT guidance. Even minimally invasive surgical techniques are difficult, as these nodules often cannot be localized unless the surgeon converts to open thoracotomy to palpate the lung.

METHODS: Sixteen patients had a percutaneous micro-coil placed in the lung, just distal to the target nodule, under CT guidance. Subsequently, the coil was localized during VATS surgery and the coil, along with the target nodule, was excised. Frozen section histological analysis was performed on the target nodule immediately and led to further resection (lobectomy), if clinically indicated. Indications for this procedure included: small nodules (0.5-2cm), deep to the pleura (>0.5cm), or non-palpable pulmonary ground glass opacities.

RESULTS: Successful localization and resection was possible in 15/16 patients leading to definitive diagnoses. Mean diameter of the target nodules was 11mm (4-17mm). Malignancies were diagnosed and treated in 10/16 patients. The other 6 patients with benign nodules received a definite diagnosis and no longer needed followup CTs. The procedure was generally well tolerated. There were no technical or surgical complications. Mortality was zero; morbidity was low—one patient had respiratory failure post-operatively and required reintubation. Median length of stay was 3 days (2-21d).

CONCLUSIONS: Using this technique it is possible to safely and accurately biopsy small non-palpable lung nodules with a minimally invasive procedure (MC-VATS), resulting in limited hospitalizations and minimal morbidities. This technique provides definitive diagnostic (and possibly therapeutic) results because the nodule is resected completely.

CLINICAL IMPLICATIONS: As CT screening for lung cancer becomes more prevalent, many patients with indeterminate pulmonary nodules will be identified. For patients needing a pathological diagnosis, MC-VATS seems to be safe and effective. This retrospective review describes our initial results with this technique and will form the basis for a future prospective trial.

DISCLOSURE: The following authors have nothing to disclose: Syed Quadri, Santiago Miro, Karl Uy, Geoffrey Graeber

We are presenting an approach for biopsy of lung nodules using a combination of interventional radiology and minimally invasive surgical techniques. This technique has been validated in animal and human experiments in the past but is not widely used in the United States.

Dept. of Surgery, UMass Memorial Medical Center/University of Massachusetts, Worcester, MA
Chest. 2012;142(4_MeetingAbstracts):35A. doi:10.1378/chest.1389707

SESSION TYPE: Thoracic Surgery I

PRESENTED ON: Monday, October 22, 2012 at 11:15 AM - 12:30 PM

PURPOSE: Endbronchial laser ablation is mainly used for treatment of endobronchial tumors. In this study, endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) was utilized for ablative therapy for target lesions located in mediastinum. We examined the efficacy of indocyanine green (ICG) enhanced laser photoablation to lung cancer in both in-vitro and ex-vivo setting. The concept of EBUS-guided ICG injection / laser ablation was tested using in-vivo porcine model.

METHODS: ICG enhanced laser photoablation (808 nm, < 250 mW) was performed in-vitro using cultured A549 lung cancer cells, and cytotoxic effect was assessed by MTS assay. Photoablation effect on human lung cancer tissue was examined using nude mouse orthotopic human lung cancer A549 Xenograft model in ex-vivo setting. EBUS guided ICG injection and laser photoablation was tested for the lymph nodes of a porcine model in in-vivo setting. The range of ablation in the treated lymph node was determined with NADH metabolic activity staining.

RESULTS: ICG enhanced laser irradiation decreased the viability of A549 cancer cells down to 20% after 5 minutes of treatment. A549 orthotopic human lung cancer Xenograft tissue was heated up to 58 °C immediately when 50ul of ICG (0.25mg/ml) was locally injected and the laser was irradiated, and the ablated tissue was negative for NADH activity. In-vivo porcine model study revealed that EBUS guided ICG injection and laser irradiation (250 mW for 3 minutes ) ablated 8 x 6 mm of area of lymph node parenchyma, while the lymph node to which saline injected and laser irradiated did not show any histological changes.

CONCLUSIONS: ICG enhanced laser photoablation exhibited sufficient cytotoxic effect in both in-vitro and ex-vivo settings. EBUS guided ICG injection and Laser photoablation successfully ablated mediastinal lymph node in a porcine model.

CLINICAL IMPLICATIONS: The study allows further investigation for the development of ICG enhanced EBUS-TBN laser ablation therapy which may be applicable to localized mediastinal lymph node metastasis.

DISCLOSURE: The following authors have nothing to disclose: Takashi Anayama, Takahiro Nakajima, Shaf Keshavjee, Kazuhiro Yasufuku

Lab use laser generator and a fiber optics were used in the study

Latner Thoracic Surgery Research Laboratory, Division of Thoracic Surgery, Department of Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada
Chest. 2012;142(4_MeetingAbstracts):36A. doi:10.1378/chest.1388876

SESSION TYPE: Thoracic Surgery I

PRESENTED ON: Monday, October 22, 2012 at 11:15 AM - 12:30 PM

PURPOSE: Over the last two decades, many studies sought to find reliable predictors of N0 status in small-sized (≤2 cm in diameter) non-small cell lung cancers (NSCLC). However, the way of tumor size measurement was usually not standardized, and controversy remains as to whether systematic lymph node dissection should be performed in patients with subcentimeter tumors. Moreover, the correlations between lung adenocarcinoma subtypes in line with the new classification and lymph node metastasis have not yet been determined specifically in small peripheral tumors.

METHODS: We reviewed association between lymph node involvement and clinicopathologic variables in 243 small peripheral NSCLC with their size measured in fresh specimens before formalin fixation. Histologic subtypes of adenocarcinomas were classified according to the new International Association for the Study of Lung Cancer (IASLC)/American Thoracic Society (ATS)/European Respiratory Society (ERS) lung adenocarcinoma classification.

RESULTS: Incidence of N1 and N2 nodal involvement was 5.3% and 6.6%, respectively. N2 disease was present in a proportion of subcentimeter tumors (2 out of 53, 3.8%). No lymph node metastasis was revealed in squamous cell carcinomas, adenocarcinoma in situ, minimally invasive adenocarcinoma, lepidic predominant adenocarcinoma or invasive mucinous adenocarcinoma. Collectively, the five cell types accounted for 34.6% of all the small peripheral cases.

CONCLUSIONS: Precise measurement of tumor size in fresh tissues revealed that tumor size was not a reliable predictor of N0 status. However, through histologic classification, systematic lymph node dissection might be avoided in more than one third of small peripheral NSCLC.

CLINICAL IMPLICATIONS: Through analysis of 243 small peripheral non-small cell lung cancers with their size measured precisely in fresh specimens, we found that tumor size alone should not be criteria to rule out systematic lymph node dissection. However, through histologic classification, omission of systematic lymph node dissection might be an alternative in more than one third of small peripheral NSCLC.

DISCLOSURE: The following authors have nothing to disclose: Yang Zhang, Haiquan Chen, Jiaqing Xiang, Yawei Zhang, Yihua Sun, Hong Hu

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Fudan University Shanghai Cancer Hospital, Shanghai, China
Chest. 2012;142(4_MeetingAbstracts):37A. doi:10.1378/chest.1389716

SESSION TYPE: Thoracic Surgery I

PRESENTED ON: Monday, October 22, 2012 at 11:15 AM - 12:30 PM

PURPOSE: Although surgical resection is the standard treatment of choice for early stage lung cancer, a significant fraction of patients develops postoperative complications due to poor preoperative conditions. To decrease the risk of morbidity, improving pulmonary function and general conditioning preoperatively should be considered essential for patients scheduled to undergo lung surgery. To date, there is no established protocol for preoperative pulmonary rehabilitation, primarily because short-term program is mandatory for patients with malignant disease to undergo surgery without delay.

METHODS: We began conventional preoperative pulmonary rehabilitation (CVPR) in 2006. From June 2009, comprehensive pulmonary rehabilitation (CHPR) was conducted prospectively using a multidisciplinary team approach. CHPR protocol consisted of multiple appointments with the physical therapist and registered dietician, and included intensive nutrition support with branched-chain amino acids (BCAAs) and herbal medicine supplementation. The transitions of pulmonary function and postoperative outcomes in CVPR (n = 29) and CHPR (n = 21) were assessed.

RESULTS: The pre- and post-vital capacity (VC) in the CHPR group were 2.63 ± 0.65 L and 2.75 ± 0.63 L (p = 0.0043), respectively; however, transition of those in the CVPR group was not statistically significant (p = 0.6815). The pre- and post-forced expiratory volume in one second (FEV1) in the CHPR group were 1.73 ± 0.46 L and 1.87 ± 0.46 L (p = 0.0012), respectively; however, transition of those in the CVPR group was not statistically significant (p = 0.6424). Morbidities in the CVPR and CHPR groups among patients with Charlson Comorbidity Index scores ≥2 were 68.8% and 27.3%, respectively (p = 0.0341), and those among patients with preoperative risk score in Estimation of Physiologic Ability and Surgical Stress scores >0.3 were 57.9% and 21.4%, respectively (p = 0.0362).

CONCLUSIONS: This study demonstrated that CHPR appeared to substantially improve pulmonary function and decrease morbidity, especially among patients with poor preoperative conditions.

CLINICAL IMPLICATIONS: We demonstrated the clinical benefit of CHPR protocol with short-term preoperative pulmonary rehabilitation in this study; however, prospective randomized studies should be conducted before such treatment can be recommended in routine clinical practice.

DISCLOSURE: The following authors have nothing to disclose: Keizo Misumi, Hiroaki Harada, Yoshinori Yamashita, Jyunichi Nakano, Jyunko Matsutani, Miyako Yamasaki, Tomomi Ohakawachi, Kiyomi Taniyama

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Hiroshima University, Hiroshima, Japan
Chest. 2012;142(4_MeetingAbstracts):38A. doi:10.1378/chest.1382017

SESSION TYPE: Surgery Case Report Posters

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Bariatric surgery is an increasingly common procedure to treat obesity. A rare complication of laparoscopic sleeve gastrectomy is gastrobronchial fistulation.

CASE PRESENTATION: A 30-year-old woman presented with a productive cough for 1 year. This was made worse when she was in a recumbent position and after meals. Over the last month, she even coughed out food particles. Her past medical history was significant for morbid obesity. A laparoscopic sleeve gastrectomy had been performed 15 months earlier. This was complicated by a persistent fundal leak secondary to staple line dehiscence resulting in a left subphrenic abscess and stenosis of the stomach body. There were also recurrent admissions for vomiting and aspiration pneumonia into the left lower lobe. Flexible bronchoscopic examination revealed no endobronchial abnormality. Bronchoalveolar lavage yielded Klebsiella species. Oesophageal stenting and dilatation of the stenosis did not improve the aspiration and she had been placed on long term feeding via a jejunostomy. However she was non compliant and was still taking orally. On examination, the patient had a temperature of 39oC. Her BMI was 23kg/m2. There was clubbing and crepitations over the left lower chest. Her chest radiograph showed a left lower zone consolidation that had been largely unchanged over the past year. A water-soluble contrast study demonstrated the presence of a gastrobronchial fistula. This was seen on computed tomography as well. She was treated for pneumonia with broad-spectrum antibiotics and underwent laparoscopic repair of the fistula.

DISCUSSION: Campos et al described 15 cases in 3 institutions specialising in the postoperative complications of bariatric surgery. There are only 8 other cases in the literature. It is a late postoperative complication. The persistent subphrenic abscess and our patient’s non-compliance to stop oral feeding contributed to the problem. The diagnosis and management requires multi-disciplinary team input and a high index of suspicion.

CONCLUSIONS: Gastrobronchial fistula after laparoscopic sleeve gastrectomy is a rare but well recognised complication that can be easily missed resulting in delayed diagnosis.

1) Buchwald H et al. Metabolic/bariatric surgery worldwide 2008. Obes Surg 2009;19(12):1605-11

2) Campos JM et al. Gastrobronchial fistula after sleeve gastrectomy and gastric bypass: endoscopic management and prevention. Obes Surg 2011;21(10):1520-29

DISCLOSURE: The following authors have nothing to disclose: Aik Hau Tan, Devanand Anantham, Pasupathy Shanker

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Singapore General Hospital, Singapore, Singapore
Chest. 2012;142(4_MeetingAbstracts):39A. doi:10.1378/chest.1388420

SESSION TYPE: Surgery Case Report Posters

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Video-Assisted Thoracoscopic Surgery (VATS) is recommended for recurrent primary spontaneous pneumothorax and for first episode if associated with incomplete expansion of the lung, persistent air leak, hemopneumothorax or associated single large bullae. Empyema complicating after chest tube is a known complication .It depends on duration of the chest tube and underlying lung disease.We are reporting a case of empyema developing within 24 hours of chest tube , without apparent lung disease ,despite on antibiotics and requiring VATS for definitive therapy.

CASE PRESENTATION: 42 year old African American woman with history of uterine fibroid and anemia presented to Emergency Department for sudden onset shortness of breath (SOB) and right sided chest pain after a straining maneuver. On Chest radiography(CXR) found to have a right pneumothorax and Wayne pig tail chest tube was placed. Follow up CXR showed small pneumoperitoneum, Computerized Tomography (CT) of abdomen revealed possible small bowel obstruction and right inguinal hernia. She was started on IVantibiotics. Patient refused laparoscopy and surgery. After 24 hours, pneumothorax resolved except for mild effusion. Patient was symptomatically better,hence the chest tube was removed .Pleural effusions were worsening in next few days ,however she signed against medical advice and following day (day 6)came to our hospital with worsening SOB, chest pain and fever. On exam, she was febrile and decreased breath sounds on entire right chest and reduced vocal fremitus CXR showed large pleural effusion with compression atelectasis which was confirmed by CT Chest(see image 1). Multiple attempts of thoracocentesis and tube thoracostomy failed to drain the effusion. Patient was started on IV antibiotics, evaluated by surgery and underwent VATS with decortication which removed more than a liter of serosanguinous loculated effusion with exuberant fibrosis. Pleural fluid LDH was high, blood and pleural fluid culture were negative. Pleural biopsy was negative for malignancy.Patient still refusing further work up for abdomen pathology.Patient was discharged home. Repeat CT Chest after 2 months revealed complete resolution of effusion (see image 2).

DISCUSSION: There are several reasons which contribute to empyema in our patient such as iatrogenic infection during tube thoracotomy or secondary infection of small hemothorax or secondary infection from intraabdominal source with diaphragmatic disruptions.Careful management of effusions after pneumothorax is vital to prevent devastating complications.

CONCLUSIONS: Primary spontaneous pneumothorax therapy is not always simple and complications do occur even after adequate sterile technique of chest tube insertion and despite receiving antibiotics.

1) Pathogenesis of posttraumatic empyema: the impact of pneumonia on pleural space infections.Hoth JJ,et al.Surg Infect (Larchmt). 2003 Spring;4(1):29-35.

DISCLOSURE: The following authors have nothing to disclose: Dharani Kumari Narendra, Frances Schmidt, Danilo Enriquez, Joseph Quist, Neerja Gulati, Muhammad Perwaiz, Setu Patolia, Rakesh Vadde, Saurav Pokharel

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Interfaith Medical Center, Brooklyn, NY
Chest. 2012;142(4_MeetingAbstracts):40A. doi:10.1378/chest.1390284

SESSION TYPE: Surgery Case Report Posters

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: We report a case of May-Thurner syndrome leading to extensive left lower extremity deep venous thrombosis (DVT).

CASE PRESENTATION: A 39 year-old-male developed acute left leg pain and swelling after several long plane flights. He was diagnosed with an acute lower extremity DVT extending from the left external iliac vein through the left posterior tibialis vein and was started on IV unfractionated heparin. Due to extensive left leg pain and swelling, the patient was referred to vascular surgery for further management. The patient underwent catheter-directed thrombolysis and mechanical thrombectomy. After clearance of clot, venography demonstrated significant left common iliac vein stenosis, consistent with a diagnosis of May-Thurner Syndrome. Balloon angioplasty and stenting of the site were performed with 0% residual stenosis. Post-procedure, the patient’s lower extremity edema and pain markedly improved. Hypercoagulable work-up revealed protein C deficiency. The patient was discharged on warfarin with a recommendation for life-long anticoagulation.

DISCUSSION: May-Thurner syndrome, or IVCS, has been described as compression of the left common iliac vein between the overlying right common iliac artery and the underlying vertebral body. The predilection for left lower extremity DVT was first reported by Virchow. A century later, May and Thurner described intraluminal spurs within the compressed left iliac vein that were hypothesized to predispose to left iliofemoral DVT formation. In fact, this anatomic pattern is seen in approximately 2-3% of normal adults, and, when associated with DVT, is often complicated by clot recurrence and/or post-phlebitic syndrome. Despite its prevalence, IVCS has often been overlooked as a cause of extensive DVT, and only recently with the use of endovascular therapies is it being diagnosed with increasing frequency. Unfortunately ultrasound of the lower extremities, and even CT venography, may not demonstrate the vascular compression. Magnetic resonance venography or endovascular venography are preferred methods of diagnosis, but these tests are not routinely ordered as part of a workup for lower extremity DVT. A randomized controlled trial by Plate et al demonstrated that in these patients, leg swelling and ulcers were nearly twice as common when patients were treated with anticoagulation alone versus anticoagulation plus surgical intervention.

CONCLUSIONS: In patients with extensive left iliofemoral DVT, one should consider an anatomic cause such as IVCS, as medical management alone may not suffice.

1) O'Sullivan GJ, Semba CP, Bittner CA, et al. Endovascular management of iliac vein compression (May-Thurner) syndrome. JVIR 2000; 11:823-836.

2) Ludwig B, Han T, Amundson D. Postthrombotic syndrome complicating a case of May-Thurner syndrome despite endovascular therapy. Chest 2006; 129:1382-1386.

DISCLOSURE: The following authors have nothing to disclose: Deirdre Kathman, John Madison, Scott Kopec

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UMass Memorial Medical Center, Worcester, MA
Chest. 2012;142(4_MeetingAbstracts):41A. doi:10.1378/chest.1386904

SESSION TYPE: Surgery Student/Resident Case Report Posters

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Colo-pericardial fistulas are exceedingly rare. They have typically occurred after esophageal replacement for other disease processes. Only one previous case has occurred in the setting of anatomically native colon which involved colonic strangulation secondary to a diaphragmatic hernia.

CASE PRESENTATION: A 58 year old man with a history of T4N0M0 cecal cancer, with invasion through the diaphragm to the right lung, presented with chest pain. He was tachycardic, hypotensive, and displayed clinical findings consistent with cardiac tamponade. A pericardiocentesis was performed, resulting in aspiration of air and feculent material. CT scan confirmed the presence of a colo-pericardial fistula. The patient was taken to the OR where a right anterior thoracotomy and laparotomy was performed. His tumor was found to be invading through the diaphragm into the middle lobe of the right lung and was densely adhered to the pericardium. En bloc resection was achieved by removing a portion of the right diaphragm, fifth and sixth ribs, pericardium, and middle lobe of the right lung. When the pericardium was incised, stool was identified in the pericardial space which was irrigated with betadine. In addition, a right hemicolectomy with primary re-anastamosis was performed. The chest and pericardial space were drained widely. The diaphragm was reconstructed with Alloderm mesh and the pericardium was left open. He had an uneventful post operative course and was discharged on post-op day 22.

DISCUSSION: This case represents the first reported colo-pericardial fistula as the result of tumor erosion. Review of the literature shows that this unique clinical entity can present as pericarditits, pneumopericardium, and cardiac tamponade. This patient’s risk for diaphragmatic tumor erosion, and eventual colo-pericardial fistulaization, was exacerbated by aberrant anatomy. Intraoperatively, he was found to have non-rotation of the midgut resulting in a redundant mesentery allowing cecum migration above the liver. This anatomic colonic variant of Chilaiditi Syndrome, placed the cecal tumor in close proximity to the pericardium. Key principles in management included broad spectrum antibiotics, adequate pre-operative resuscitation, and surgical drainage.

CONCLUSIONS: Though now fatal in 50% of reported cases (4/8), colo-pericardial fistulas are a surgically treatable condition that should be considered when patients with colonic tumors present with the cardiac symptoms as described above.

1) Wetsetein L, Ergin M, Griepp R (1982) Colo-Pericardial Fistula: Complication of Colonic Interposition. Texas Heart Institute Journal 9:373-375

2) Jouret F, Castanares-Zapatero D, Laterre P (2010) Delayed colopericardial fistula and pyopneumopericardium. Intensive Care Medicine 36:557-558

3) Parmar J, Probert C, Clarke D, Temple J (1989) Colo-pericardial and colo-caval fistula: Late complication of colon interposition. European Journal of Cardio-thoracic Surgery 3:371-372

DISCLOSURE: The following authors have nothing to disclose: Travis Cotton, Benjamin Haithcock, Mark Joseph

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UNC Hospitals, Chapel Hill, NC
Chest. 2012;142(4_MeetingAbstracts):42A. doi:10.1378/chest.1390389

SESSION TYPE: Surgery Student/Resident Case Report Posters

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Gastropulmonary fistulas are exceedingly rare and usually present as a complication after an esophagectomy or bariatric surgery. There are some reports of unusual late complications of fistulization associated with hiatal hernias. We present the case and management of a patient who presented with recurrent pneumonias from a gastropulmonary fistula, in the setting of a longstanding diaphragmatic hernia.

CASE PRESENTATION: A 55 year old male with a history of COPD and known diaphragmatic hernia presented in respiratory distress and a history of recurrent pneumonias over a period of 2 years. His initial admission involved a GI bleed with symptoms of fever and cough and postprandial cough. Chest radiographs showed an infiltrative process with a CT scan revealing a large cavitary lesion at the left lung base abuting the gastric fundus. He was treated with IV antibiotics and discharged twice only to be readmitted within 72hrs of discharge. During both readmissions, he was treated with IV antibiotics and steroids for respiratory failure, thought to be from multidrug resistant pneumonias. Past medical history was significant for a remote history of right thoracotomy and known diaphragmatic hernia from a penetrating stab wound 30 years prior. On arrival, the patient was placed on a ventilator for respiratory distress. An UGI study was performed showed a small outpouching of the gastric fundus overlying the left lung base, suggestive of gastropulmonary fistula. Despite high PEEP, he maintained poor oxygen saturations due to severe ARDS and developed significant abdominal distension despite good bowel decompression. He eventually underwent resection of gastropulmonary fistula and diaphragmatic repair, pulmonary decortications via a thoracoabdominal incision with single lung ventilation.

DISCUSSION: Gastropulmonary fistulas with ARDS pose a diagnostic as well a therapeutic challenge. Due to the persistent pneumonias, history of COPD and development of ARDS, the patient was not the ideal candidate for a prolonged surgical repair. However, needing positive pressure ventilation in the setting of a gastropulmonary fistula also made oxygenation very challenging. With increases in PEEP and tidal volume, this in turn caused increased gastric distention and loss of volume. In this case, the patient was initially treated with nasogastric tube decompression and IV antibiotics and aggressive diuresis for ARDS. This allowed an elective surgical procedure rather than an emergent one in the case of a critically ill patient with comorbid conditions.

CONCLUSIONS: Gastropulmonary fistulas are exceedingly rare, thus posing a diagnostic as well a therapeutic challenge. Careful preoperative planning with a multi disciplinary team can often assist in the optimization of these patients prior to surgery.

1) Doubit M, Doubit G, Shamji FM et al. Gastropulmonary fistula after bariatric surgery. Can J Gastroenterol 2009;23(3):215-216.

DISCLOSURE: The following authors have nothing to disclose: Mark Joseph, Benjamin Haithcock

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University of North Carolina at Chapel Hill, Chapel Hill, NC
Chest. 2012;142(4_MeetingAbstracts):43A. doi:10.1378/chest.1390809

SESSION TYPE: Surgery Student/Resident Case Report Posters

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Thymoma is an uncommon and slow-growing neoplasm and is the most common primary anterior mediastinal tumors in adults. Patients are usually asymptomatic, but can also present with respiratory symptoms, superior vena cava syndrome, or paraneoplastic syndromes. We present a rare case of an invasive thymoma with intraluminal thrombus involving the left brachiocephalic vein, superior vena cava and right atrium presenting with superior vena cava syndrome and pulmonary embolism.

CASE PRESENTATION: 64 year old male presented to his primary care physician with an acute left upper extremity swelling of two weeks duration. Venous duplex of the upper extremities showed an acute deep venous thrombosis in the left internal jugular, left subclavian and axillary veins. CT of the chest with intravenous contrast revealed a 5 cm anterior mediastinal mass with calcifications and a large sub-occlusive thrombus in brachiocephalic, bilateral subclavian veins, and right atrium and minimal flow through the SVC (Figure 1). MRI confirmed a 6.5 x 3.5 x 3 cm anterior mediastinal mass which did not appear to be compressing or invading the great vessels, in addition there was a thrombus extending from bilateral subclavian, brachiocephalic veins, SVC into right atrium (Figure 2). After suffering from a pulmonary embolus, patient underwent an urgent pulmonary embolectomy, mediastinal mass excision, removal of right atrial, SVC and innominate vein clots and a single vein bypass to LAD as patient had a 70% proximal LAD lesion on preoperative cardiac catheterization. Pathology report indicated a mixed type thymoma (type A and AB for right atrial mass and SVC clot, respectively) according to the WHO histological typing with stage III according to Masaoka’s staging. Postoperatively patient recovered well, and was offerred radiation therapy for local control.

DISCUSSION: Several mechanisms have been proposed to explain the mode of brachiocephalic vein infiltration including extension through the thymic veins, direct invasion, and hematogenous spread. Since no direct invasion was observed, it appears that the mode of extension occurred from the thymic veins and propagated intraluminally through the great veins into the heart. Thus, thymic veins must be carefully examined during the time of resection to warrant absence of residual tumor.

CONCLUSIONS: In conclusion, intraluminal extension of thymic cancer into the great vessels and cardiac cavity is an infrequent occurrence, however, complete excision of the mediastinal mass, evacuation intracardiac thrombi can be performed with cardiopulmonary with excellent outcome.

1) Yamazaki, K., et al., Thymic carcinoma presenting as an intraluminal growth into the great vessels and the cardiac cavity. Ann Thorac Cardiovasc Surg, 2002. 8(3): p. 163-6.

DISCLOSURE: The following authors have nothing to disclose: Mina Guerges, Iosif Gulkarov

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Ross University School of Medicine, North Brunswick, NJ
Chest. 2012;142(4_MeetingAbstracts):44A. doi:10.1378/chest.1371402

SESSION TYPE: Surgery Student/Resident Case Report Posters

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Bronchogenic and esophageal duplication cysts are congenital malformations of the bronchopulmonary foregut during embryonic development. In adults, these rare cysts are typically found incidentally in asymptomatic patients. Computed tomography, endoscopic ultrasound and magnetic resonance imaging can help differentiate these cysts from other mediastinal tumors and aid in the diagnosis by demonstrating characteristic locations and features of near water density. Due to the high risk of developing symptoms and complications such as cough, dyspnea, infection, airway compression or even tension pneumothorax, surgical resection of the cyst is considered first-line treatment even in the asymptomatic patient. We discuss a rare case of an adult presenting with hemoptysis who was found to have both a bronchogenic cyst and an esophageal duplication cyst.

CASE PRESENTATION: A 44 year old African American woman with a history of chronic obstructive pulmonary disease and a right hilar mass presumed to be a bronchogenic cyst presented with an episode of hemoptysis and right-sided chest pain. Her right hilar mass was followed for nine years by her pulmonologist. An MRI done upon admission showed two benign appearing cystic mediastinal lesions of the right chest. The largest of these was within the right medial infrahilar region abutting the azygo-esophageal recess and measured 5.0 x 4.9cm and the second lesion in the right paratracheal location measured 2.4 x 2.4 cm (Figure 1 & 2). The patient underwent bronchoscopy which showed no evidence of active bleeding. Cardiothoracic surgery was consulted and performed a right thoracotomy, removing these two cystic lesions. The pathology confirmed that the larger infrahilar cyst was a bronchogenic cyst and the smaller paratracheal cyst was an esophageal duplication cyst.

DISCUSSION: Our case describes the rare event of a patient presenting with both a bronchogenic cyst and an esophageal duplication cyst. In our presentation, we will discuss the etiology, clinical sequelae, diagnosis, and management of bronchogenic and esophageal duplication cysts in adults.

CONCLUSIONS: Our patient underwent two unique events during embryologic development of the foregut that likely occurred at 28 days during the time of cleavage of the respiratory and digestive tract. These events determined the anomalous location of these cellular components. To our knowledge, this is the first report in the literature that found both types of bronchogenic & esophageal duplication cysts in the same patient.

1) Patel SR, Meeker DP, Biscotti CV, Kirby TJ, Rice TW. Presentation and management of bronchogenic cysts in the adult. CHEST 1994;106:79-85.

2) Cioffi U, Bonavina L, De Simone M, Santambrogio L, Pavoni G, Testori A, Peracchia A. Presentation and surgical management of bronchogenic and esophageal duplication cysts in adults. CHEST 1998;113:1492-1496.

DISCLOSURE: The following authors have nothing to disclose: Philip Svigals, Carlos Kummerfeldt, Nathaniel Piel, Robert Miller, Nicholas Pastis

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Medical University of South Carolina, Charleston, SC
Chest. 2012;142(4_MeetingAbstracts):45A. doi:10.1378/chest.1390777

SESSION TYPE: Surgery Student/Resident Case Report Posters

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Angina occurs when myocardial oxygen demand exceeds oxygen supply; the clinical manifestation is often chest discomfort. Several non-atherosclerotic conditions have been studied and reported in literature that cause angina in rarity.

CASE PRESENTATION: A 40 year old Chinese healthy male presented to the emergency department with chest pain described as heavy, retrosternal, non-radiating, constant for 30 minutes associated with dizziness, nausea and palpitations which started while lifting a weight of 40 pounds. It relieved gradually with rest. His physical activity was limited due to the chest discomfort (CCS Class II angina). He had a smoking history of 10 packs per day without alcohol or illicit substance use and an insignificant family history. His physical exam was positive for grade II/VI continuous murmur at the left sternal border, with clear lungs and normal jugular venous pressure. His exercise stress test which was terminated at 7 minutes as he developed dizziness, ST segment depression in the lateral leads along with non-sustained ventricular tachycardia and a transient left bundle branch block. Cardiac catheterization showed insignificant coronary artery disease but revealed a fistula leading from the Left anterior descending (LAD) to the main pulmonary artery. This was confirmed by Coronary CT angiogram coursing within the epicardial fat along the lateral aspect of the pulmonary outflow tract. An attempt to coil the fistula via the pulmonary circulation was unsuccessful. Robotic arm assisted ligation in the operating room showed a 1-cm long feeding vessel coming off the LAD with only one visualized branch, which was isolated and ligated close to the LAD. TEE was used to confirm the presence and absence of flow. This resulted in patient recovery without any complications.

DISCUSSION: A coronary artery fistula (CAF) is an abnormal communication between an epicardial coronary artery and a cardiac chamber or a major vessel. They may present at any age and are mostly congenital. Whether or not a patient will develop symptoms depends on the degree of volume overload and severity of the left to right shunt. Coronary angiography still remains the gold standard for diagnosis. Surgical ligation and transcatheter embolization are known treatment options for CAF.

CONCLUSIONS: Our patient presented with symptoms of stable angina, further unmasked during exercise stress testing. His symptoms are explained by the “steal” phenomenon where coronary blood flow is shunted to the pulmonary artery at the expense of myocardium, resulting angina. Symptoms abated after successful ligation of the fistula using a robotic arm.

1) Heart failure with transient left bundle branch block in the setting of left coronary fistula. Juraschek SP, Kovell LC, Childers RE, Chow GV, Hirsch GA. Source Department of Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, 4940 Eastern Avenue, Baltimore, MD 21224, USA

DISCLOSURE: The following authors have nothing to disclose: V Subbarao Boppana, Sravanthi Nandavaram, Sidharth Jogani, Robert Carhart

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Suny Upstate Medical Center, Syracuse, NY
Topics: angina pectoris , lung , heart
Chest. 2012;142(4_MeetingAbstracts):46A. doi:10.1378/chest.1387244

SESSION TYPE: Surgery Student/Resident Case Report Posters

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: The neurofibromatosis type 1 is an autosomal dominant, hamartomatous, characterized by the presence of multiple neurogenic tumors, usually neurofibromas associated with skeletal lesions.

CASE PRESENTATION: A 33-year-old female with a 14x7 cm right upper mid-mediastinal mass with neck extension through the thoracic outlet was resected with limited access techniques. She has Von Recklinghausen disease. Complained since 2007, of a left cervical 3 cm hard, painless, mobile tumor. This mass increased in size for the last 4 years, limiting cervical mobility; hoarseness, dyspnea and progressive dysphagia to liquids and paresthesias in the left upper limb. A contrast chest and neck CT showed two main tumors., One in level II, III and IV on left side of the neck and a second 14x7cm heterogeneous mass arising from the right mid upper mediastinum with intrathoracic and neck extension.During assessment, left vocal cord paralysis with compensatory movement of right vocal cord was observed.A month later she was readmitted for resection of her right mediastinal mass.

DISCUSSION: Initially right VATS evaluation and dissection of the thoracic portion of the mediastinal mass was performed. After manuvering the thoracic outlet limited dissection a partial upper sternotomy to the 2nd ICS with right sternal split and cervical extension was performed, Tumor dissection in the anterior mediastinum and cervical area was completed, removing the tumor completely en-bloc with the right phrenic nerve. A 24 Fr Blake drain was left in the right chest and mediastinum. The histopathological report confirmed the diagnosis of neurofibroma of the intrathoracic frenic nerve. Postoperatively, the patient had asymptomatic right diaphragmatic paralysis.Discharged from our service on the seventh day

CONCLUSIONS: We present this case to present the application of minimal access techniques (right VATS) in large mediastinal tumors can minimize the extent to a single incision (median sternotomy) with subsequent faster recovery and decreased postoperative complications and hospital stay

1) Osborn A. Neurorradiología diagnóstica. Madrid: Mosby; 1996. p. 72- 85. 2. Dones Carvajal JJ, Camacho Pastor MA, Lea Pereira MC, García To- rrecillas JM, Fernández Reyes JL, Molina Molina F. Varón de 62 años con lesiones cutáneas de larga evolución: un diagnóstico a primera vista. Rev Clin Esp 2001;201:53-5.

2) Kreel L, Al-Kutoubi M. Two varieties of rib notching. Postgrad Med J 1991;67:568-70. 4. Bourgouin P, Shepard J, Moore E, McLoud T. Plexiform neurofibro- matosis of the mediastinum: CT appearance. AJR 1988;151:461-3.

3) Felson B. Radiología Torácica. 2.a ed. Filadelfia. WB Saunders Com- pany; 1994. 6. Dacher JN, Zakine S, Monroc M, Eurin D, Lechevallier J, le Dosseur P. Rib displacement threatening the spinal cord in a scoliotic child with neuro- fibromatosis. Pediatr Radiol 1995;25:58-9.

DISCLOSURE: The following authors have nothing to disclose: Francina Bolaños, Hugo Luna, Sylvain Collura, Herrera Zamora Julio de J, Luis Marcelo Argote

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National Institute for Medical Science and Nutrition “Salvador Zubirán”, México, Mexico
Chest. 2012;142(4_MeetingAbstracts):47A. doi:10.1378/chest.1378016

SESSION TYPE: Thoracic Surgery II

PRESENTED ON: Tuesday, October 23, 2012 at 04:30 PM - 05:45 PM

PURPOSE: Since the randomized controlled study of sublobar resection vs. lobectomy for stage I NSCLCs by the Lung Cancer Study Group (LCSG), there have been improvements in staging. Also, the liberal use of computerized tomography may have altered the types of early lung cancer diagnosed. Studies published since then have drawn contradictory conclusions on the benefit of lobectomy over sublobar resections for early stage NSCLC. We examined the SEER database to assess the influence of these evolving factors on the relationship between the extent of resection and survival over the last two decades.

METHODS: Stage I NSCLCs < 2cm in size were examined over three time periods: 1988 - 1998 (Early), 1999 - 2004 (Intermediate) and 2005 - 2008 (Late). For each period, overall and disease-specific survival and their association with extent of resection was assessed by univariate and multivariate analyses. Sublobar resections in the ”Early” group could not be categorized into segmentectomies and wedge resections as these were not coded separately.

RESULTS: The proportion of NSCLCs < 2cm increased from 0.98% in 1988 to 2.2% in 2008. Multivariate analyses showed that sublobar resection was inferior to lobectomy in the “Early” period (HR=1.41; 95%CI=1.21-1.65). This effect decreased in the “Intermediate” period where segmentectomies but not wedge resections were equivalent to lobectomies (Wedge vs. Lobectomy HR = 1.19; 95%CI=1.01 - 1.41; Segmentectomy vs. Lobectomy HR =1.04; 95%CI=0.8-1.36). The difference disappeared in the “Late” period where both wedge resections and segmentectomies were equivalent to lobectomy(Wedge vs. Lobectomy HR = 1.09; 95%CI=0.79 - 1.5; Segmentectomy vs. Lobectomy HR =0.83; 95%CI=0.47-1.45). The trends for both overall survival and disease specific survival were identical.

CONCLUSIONS: The survival benefit of lobectomy over sublobar resection decreased over the last two decades with no discernible difference in the most contemporary cases.

CLINICAL IMPLICATIONS: These results support the hypothesis that better staging and earlier detection of less aggressive disease due to the expanding use of computerized tomography and PET/CT may make the results of the LCSG irrelevant to current clinical practice.

DISCLOSURE: The following authors have nothing to disclose: Sai Yendamuri, Rohit Sharma, Adrienne Groman, Austin Miller, Todd Demmy

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Roswell Park Cancer Institute, Buffalo, NY
Chest. 2012;142(4_MeetingAbstracts):48A. doi:10.1378/chest.1390684

SESSION TYPE: Thoracic Surgery II

PRESENTED ON: Tuesday, October 23, 2012 at 04:30 PM - 05:45 PM

PURPOSE: Sublobar resection is re-emerging as an alternative to lobectomy in the management of small, early-stage non-small cell lung cancers. However, the potential advantages of thoracoscopic segmentectomy compared to thoracoscopic lobectomy remained undefined. We hypothesize that thoracoscopic segmentectomy has comparable peri-operative morbidity profiles when compared to thoracoscopic lobectomy in patients undergoing lung resection for clinical stage I non-small cell lung cancer.

METHODS: Patients undergoing thoracoscopic segmentectomy (n=163) or lobectomy (n=190) for clinical stage I non-small cell lung cancer were identified from a prospectively maintained single-institution database. All patients had histologically confirmed non-small cell lung cancer resected thoracoscopically. Primary outcomes included morbidity, mortality, length of hospital stay, readmission rate, as well as disease-free survival. Comparisons were performed with the Student’s t-test and Fisher’s exact test. Actuarial estimates of recurrence-free survival were performed utilizing the Kaplan-Maier method, with significance being assessed via the log rank test.

RESULTS: There were no differences in age and gender distribution between patients undergoing lobectomy and segmentectomy. Patients undergoing lobectomy had larger tumors (mean 2.5 cm vs. 1.9 cm, p<0.001). Overall morbidity (36.8% vs. 31.9%), mortality (0.5% vs. 0.6%), length of hospital stay (5 vs. 6 days), 30-day readmission rate (7.9% vs. 8.6%), as well as recurrence-free survival (58 vs. 53%) were similar between groups. The most common complication was atrial fibrillation (Segment=6.7%; Lobe=4.7%, p=0.49). The most common major complication was pneumonia (Segment=11.0%; Lobe=12.1%, p=0.87). There were no significant differences in morbidity when comparing individual segments to their corresponding lobes. Similarly, there was no significant difference in morbidity profile when comparing upper lobe vs. lower lobe resections.

CONCLUSIONS: Thoracoscopic segmentectomy has comparable perioperative outcomes and morbidity profiles when compared to thoracoscopic lobectomy in the setting of stage I non-small cell lung cancer. These findings will need to be validated by prospective randomized comparisons (CALGB 140503).

CLINICAL IMPLICATIONS: Thoracoscopic segmentectomy can be performed with acceptable oncologic and morbidity outcomes for clinical stage I non-small cell lung cancer.

DISCLOSURE: The following authors have nothing to disclose: Nikiforos Ballian, Matthew Schuchert, David Wilson, Daniel Normolle, Joshua Landreneau, Andre Pitanga, Jamilly Gomes, Felipe Franca, Ghulam Abbas, Omar Awais, Neil Christie, James Luketich, Rodney Landreneau

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University of Pittsburgh, Pittsburgh, PA
Chest. 2012;142(4_MeetingAbstracts):49A. doi:10.1378/chest.1386738

SESSION TYPE: Thoracic Surgery II

PRESENTED ON: Tuesday, October 23, 2012 at 04:30 PM - 05:45 PM

PURPOSE: Controversy remains over the routine use of invasive (such as mediastinoscopy) or expensive (such as positron emission tomography) diagnostic procedures in stage T1 non-small cell lung cancer (NSCLC) without lymph node enlargement on computed tomography (CT) as the risk of mediastinal lymph node metastasis is comparatively low in such patients. We aimed to develop a prediction model for N2 disease in CT defined T1N0 NSCLC to aid in the decision-making process.

METHODS: We reviewed the records of 530 CT defined T1N0 NSCLC patients who underwent surgical resection with systematic lymph node dissection. Correlations between N2 involvement and clinicopathological parameters were assessed using univariate analysis and binary logistic regression analysis. A prediction model was built on the basis of logistic regression analysis, and was internally validated using bootstrapping.

RESULTS: Incidence of N2 disease was 16.8%. Four independent predictors were identified in multivariate logistic regression analysis and were included in the prediction model: age at diagnosis (OR = 0.974; 95% CI: 0.952-0.997), tumor size (OR = 2.769; 95% CI: 1.818-4.217), central tumor location (OR = 3.204; 95% CI: 1.512-6.790), and invasive adenocarcinoma histology (OR = 3.537; 95% CI: 1.740-7.191). Hosmer-Lemeshow test of goodness-of-fit was not significant (P = 0.784), suggesting a high concordance between predicted and observed probabilities. The area under the ROC curve, which measures the model’s accuracy, was reasonable (0.726, 95% CI: 0.669-0.784). Internal validation by bootstrapping showed the bias corrected area under the ROC curve was 0.717, and the extent of “over-optimism” is minimal (0.009, 1.2%), indicating that this prediction model holds for future patients.

CONCLUSIONS: We developed a four-predictor model that can estimate the probability of N2 disease in CT defined T1N0 NSCLC. This prediction model can help to determine the cost-effective utilization of mediastinal staging procedures.

CLINICAL IMPLICATIONS: The predicted likelihood of N2 nodal involvement has implications for the cost-effective utilization of diagnostic procedures, such as mediastinoscopy and PET, in staging mediastinal lymph nodes in CT defined T1N0 NSCLC.

DISCLOSURE: The following authors have nothing to disclose: Yang Zhang, Yihua Sun, Jiaqing Xiang, Yawei Zhang, Hong Hu, Haiquan Chen

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Department of Thoracic Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
Chest. 2012;142(4_MeetingAbstracts):50A. doi:10.1378/chest.1390785

SESSION TYPE: Thoracic Surgery II

PRESENTED ON: Tuesday, October 23, 2012 at 04:30 PM - 05:45 PM

PURPOSE: Lobectomy with complete mediastinal lymphadenectomy is considered standard for patients with early stage non-small cell lung cancer (NSCLC), but frequently results in unnecessary dissection associated with increased morbidity. Since lobe specific nodal drainage patterns are predictable, we hypothesized that lobe-specific lymph node dissection in such patients is sufficient. Therefore, the purpose of this study was to analyze the frequency and pattern of mediastinal nodal disease and its impact on tumor recurrence.

METHODS: All patients with clinical N0/N1 NSCLC determined by means of computed tomographic (CT) and positron emission tomographic (PET) analyses were identified. Disease involvement of surgically dissected nodal stations was recorded. Patterns of recurrence of those who underwent lobectomy with complete mediastinal lymph node (LN) dissection were compared to those who underwent lobe-specific mediastinal lymph node dissection.

RESULTS: From July 2004 to April 2011 there were 390 patients identified. Complete mediastinal LN dissection was performed in 294 patients (28 underwent lobectomy by thoracotomy and 263 had attempted thoracoscopic resection, 74 of which were converted to thoracotomy). Fifteen patients (5.1%) were found to have N2 disease after pathological evaluation. The only tumor characteristic that associated with increased risk of N2 disease in these patients was laterality of the tumor. Patients with left sided tumors were more likely to have pathological N2 disease than patients with right sided tumors (8.4%[10/119] versus 2.9%[5/175]; p=0.03). Only 1 patient with an upper lobe tumor had mediastinal metastasis to level 7 without involvement of level 4 mediastinal nodes (0.3%). Also, patients with complete LN dissection had similar rate of recurrence compared to the group that had lobe-specific mediastinal LN dissection (23.9% vs. 21.3%).

CONCLUSIONS: Mediastinal N2 metastases follow predictable patterns in patients with negative preoperative CT and PET scans. Exceptions are rare. Finally, there is no significant increase in the recurrence rate in patients with lobe specific versus complete mediastinal nodal dissection.

CLINICAL IMPLICATIONS: Lobe-specific mediastinal nodal evaluation is acceptable in patients with early stage NSCLC.

DISCLOSURE: The following authors have nothing to disclose: Mark Shapiro, Sakar Kadakia, Andrew Breglio, Andrew Kaufman, Dong-Seok Lee, Raja Flores

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The Mount Sinai Medical Center, New York, NY
Chest. 2012;142(4_MeetingAbstracts):51A. doi:10.1378/chest.1390665

SESSION TYPE: Thoracic Surgery II

PRESENTED ON: Tuesday, October 23, 2012 at 04:30 PM - 05:45 PM

PURPOSE: Hilar tumors present significant surgical and oncological challenges, particularly in cases where pneumonectomy may be required. Nonetheless, tumors with clinical N0 status mandate surgical consideration. Our objective was to evaluate the clinical outcome of patients undergoing pneumonectomy compared with lobectomy (with or without bronchoplasty) for clinical stage IB-IIB lung cancers.

METHODS: 253 patients (60 pneumonectomies, 70 sleeve resections, 123 lobectomies) with clinical stage IB-IIB NSCLC based on CT radiographic hilar involvement were evaluated. Mean tumor size was 4.7 cm. Outcome variables included morbidity, mortality, recurrence and survival. Comparisons between groups were performed utilizing the t-test and Fisher’s exact test. Overall and recurrence-free survival estimates were performed utilizing the Kaplan-Maier method.

RESULTS: The pneumonectomy group was younger than the sleeve resection (63.4 vs. 66.0, p=0.15) and lobectomy groups (63.4 vs. 68.4, p=0.001), and were more commonly of male gender (p=0.020). Perioperative mortality was higher in the pneumonectomy group at both 30 (6.7% vs. 1.4% vs. 0.8%) and 90 (13.3% vs. 5.7% vs. 2.4%) days when compared to sleeve resection and lobectomy. Mean follow-up was 28.7, 26.6 and 31.6 months for pneumonectomy, sleeve resection and lobectomy, respectively. Recurrence-free survival was similar between groups (Pneumonectomy - 26% vs. Sleeve Resection - 34% vs. Lobectomy - 44%), though there was a trend favoring lobectomy [p>0.077]. Pneumonectomy was associated with reduced overall survival when compared to lobectomy (30% vs. 40% at 5 years, p=0.040). An increased rate of tumor upstaging was observed in the pneumonectomy patients (30%) when compared to sleeve resection (22.8% and lobectomy (22.0%). By comparison, peripheral Stage IB-IIB tumors (n=307) resected at our institution during this same time period were associated with a significantly increased survival (55% vs. 33% at 5 years, p=0.026).

CONCLUSIONS: Large, hilar, clinically N0 malignancies have differential outcomes unique to their anatomic location, especially when compared to more peripheral tumors. However, this group has a higher perioperative mortality and oncologic risk of recurrence regardless of procedure performed.

CLINICAL IMPLICATIONS: Mature surgical expertise and judgment is required to promote the appropriate use of lobectomy or sleeve resection rather than reflexively employing pneumonectomy for hilar tumors, although this approach may be necessary for selected patients.

DISCLOSURE: The following authors have nothing to disclose: Matthew Schuchert, Ryan Macke, Ghulam Abbas, Andre Pitanga, Joshua Landreneau, Omar Awais, Arjun Pennathur, Peter Ferson, Neil Christie, James Luketich, Jill Siegfried, David Wilson, Rodney Landreneau

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University of Pittsburgh Medical Center, Pittsburgh, PA
Chest. 2012;142(4_MeetingAbstracts):52A. doi:10.1378/chest.1388899

SESSION TYPE: Thoracic Surgery Posters I

PRESENTED ON: Wednesday, October 24, 2012 at 01:30 PM - 02:30 PM

PURPOSE: The pathogenesis of upper airway stenosis (UAS) in burned patients combines the effects of inhaled gases, heat and usually intubation. The persistence of inflammatory signs, length and complexity of these lesions seems to be greater than other benign stenosis. The aim of this study was to describe the presentation,treatment and results of a group of patients evaluated for UAS after inhalation injury.

METHODS: All patients with UAS after inhalation injury evaluated by the authors from January 2006 to January 2011 were included. All the surgical centers were approved by national or provincial health department to perform this kind of procedures. The demographics,lesion description, initial and definitive management and surgical results were prospectively recorded.

RESULTS: A total of 10 patients were included (males 5, females 5). Mean age was 31 years (18 to 41 years). Mean follow-up: 41 months (12 to 72 months).Seven patients had combined laryngeal and tracheal lesions. There were 8 Laryngeal (1 unilateral vocal cord paralysis, 1 aritenoid fixation and 6 subglottic stenosis), 8 proximal and mid tracheal and 1 lower tracheal lesions. Phonation was impaired in 5 patients. Initial management was tracheostomy in 4 patients, tracheal stent placement in 3 ,surgical resection in 2 and rigid bronchoscopic dilation in 1. Definitive laryngotracheal resections were performed in 9 patients. The other one had a permanent tracheal stent. Time from inhalation injury to surgery was 12,6 months (6 to 24 months). Mean Length of resection was 4 cm (3 to 6 cm). One patient presented an anastomotic granuloma (resolved with laser resection) and other a restenosis (treated with stent placement). Both of them were operated before one year of the airway injury. There were not other complications nor deaths.

CONCLUSIONS: Most of the UAS observed were extense and almost all involved the larynx and trachea (7 cases). The results of surgical treatment were excellent when postponed until endoscopic signs of inflammation succeeded and large tracheal resections could be performed without significant complications. All the patients with phonation impairment recovered vocal communication.

CLINICAL IMPLICATIONS: Laryngotracheal resection should be the main therapeutic option in the management of this complex group of patient. Although it is important to have other tools that allow the patient to be safe when waiting for the perfect surgical spot.

DISCLOSURE: The following authors have nothing to disclose: Fernando Abdala, Oscar Abdala

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Sanatorio de Los Arcos, Buenos Aires, Argentina
Chest. 2012;142(4_MeetingAbstracts):53A. doi:10.1378/chest.1365828

SESSION TYPE: Thoracic Surgery Posters I

PRESENTED ON: Wednesday, October 24, 2012 at 01:30 PM - 02:30 PM

PURPOSE: In response to an identified association of prolonged urinary catheterization with urinary tract infections (UTI’s), the Centers of Disease Control established a 1b recommendation guiding postoperative removal of urinary catheters within 24 hours unless otherwise indicated. In general thoracic surgical patients receiving thoracic epidural analgesia, current practice dictates maintaining urinary catheterization for the duration of the epidural to prevent urinary retention. The purpose of this study was to evaluate urinary retention rates when urinary catheters were discontinued within the first 24 hours post-op during uninterrupted epidural analgesia.

METHODS: All general thoracic surgery patients with thoracic epidural analgesia were considered for inclusion in a prospective, observational study during a seven-month period. Exclusion occurred if patients were <18, male >65, had a history of urologic procedures or urinary retention, known benign prostatic hypertrophy, or admitted to ICU. Informed consent was obtained. Data points collected included location of epidural; time and amount of spontaneous void; urinary bladder scanning results; time of epidural discontinuation and presence of UTI defined by CDC guidelines. Urinary catheter discontinuation was scheduled for midnight on the operative day. Urinary retention was identified at >400cc determined by bladder scan. The study was Institutional Review Board approved.

RESULTS: 69 general thoracic surgery patients with thoracic epidurals were considered for study over a seven-month time period. Of those, 46 qualified. The urinary catheters of 39 patients were removed within 24 hours post-op. Seven patients did not receive a urinary catheter. SPSS was utilized for analysis. Of the 46 patients, 2% had urinary retention.

CONCLUSIONS: Urinary catheter removal within 24 hours post-op in carefully selected general thoracic surgery patients receiving uninterrupted thoracic epidural analgesia resulted in a low incidence of urinary retention.

CLINICAL IMPLICATIONS: In select populations of general thoracic surgery patients with thoracic epidurals, removal of urinary catheters is safe and complies with the CDC recommendations.

DISCLOSURE: The following authors have nothing to disclose: Laurel Rhyne, Tiffany Potter, J. Robert Headrick

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Memorial Health Care System, Chattanooga, TN
Chest. 2012;142(4_MeetingAbstracts):54A. doi:10.1378/chest.1389841

SESSION TYPE: Thoracic Surgery Posters I

PRESENTED ON: Wednesday, October 24, 2012 at 01:30 PM - 02:30 PM

PURPOSE: CT guided injection of technetium can be used to localize pulmonary nodules that are either too small, or lack a sufficient solid component to be identified during a Video Assisted Thoracic Surgery (VATS) approach. Furthermore localization may prevent the inadvertent traversing of a potential cancer and thus preserve a margin of normal tissue around the resected lesion, the merits of which are at the very core of surgical oncology. We evaluated our single institution’s experience with this technique to evaluate the types of nodules localized, the success rates of localization, and the ability to obtain a negative margin for wedge-resected malignancies.

METHODS: A retrospective review was performed on a prospectively maintained database.

RESULTS: From 2006 to 2011, CT-guided technetium injection was used to localize 58 nodules in 54 patients. The median size of the pulmonary nodule was 1.2 cm +/- 0.6 cm. Overall 44.8% of the nodules were almost entirely ground glass (Suzuki 1 or 2), 17.2% were purely solid (Suzuki 6) while 32.8% were mixed (Suzuki 3, 4, 5). The median distance of the nodule from the innermost chest wall or nearest fissure was 0.61cm (range 0-3.2), and the median time from needle localization to the beginning of the procedure was 191min (range 79-348). A pneumothorax developed in 6 patients as a result of the localization procedure, with only one requiring an intervention prior to surgery (pig tail catheter). Overall 96% of nodules were successfully identified by VATS following localization (56/58). Excised nodules represented primary lung cancer (60%), pulmonary metastases (16%), and benign lesions (24%). Of the malignant nodules, 98% were removed with a negative margin.

CONCLUSIONS: CT guided technetium injection is an effective technique to localize small or predominantly ground glass pulmonary nodules unlikely to be palpable during a VATS resection. Technetium localization allows the nodule to be adequately positioned within a wedge to consistently obtain negative margins.

CLINICAL IMPLICATIONS: Localization allows clinicians to utilize wedge resection for the diagnosis and treatment of early lung cancer as imaging captures progressively more subtle lung cancers. Further study is needed to evaluate the ability of technetium localized wedge resection to provide local control of pulmonary malignancies.

DISCLOSURE: The following authors have nothing to disclose: Ankit Dhamija, Eric Reiner, Ami Rubinowitz, Xiaojie Guo, Mary Finan, Anthony Kim, Frank Detterbeck, Daniel Boffa

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Morristown Medical Center, Morristown, NJ
Chest. 2012;142(4_MeetingAbstracts):55A. doi:10.1378/chest.1388929

SESSION TYPE: Thoracic Surgery Posters I

PRESENTED ON: Wednesday, October 24, 2012 at 01:30 PM - 02:30 PM

PURPOSE: Primary lung cancer patients who underwent preoperative induction therapy were examined, and the relationships among pre- and postoperative trends in the maximal standardized uptake value (SUVmax) on 18F-fluorodeoxyglucose positron emission tomography (FDG-PET), treatment success rate, and histopathological findings were investigated.

METHODS: One thousand and six patients underwent surgery for primary lung cancer at our center between January 2005 and December 2011. Of these patients, 72 (7.2%) received preoperative induction therapy. Following preoperative induction therapy, 42 cases underwent FDG-PET. The pathological stage before induction therapy was IIB/IIIA/IIIB = 13/19/10. Thirty seven patients received radiotherapy+chemotherapy (CRT), and five received chemotherapy only. In the CRT group, radiotherapy was done concurrently in all cases. The SUVmax of the tumor and lymph nodes on FDG-PET was measured before and after induction, and the decrease rate in SUVmax (SDR) was calculated as 1 − (pretreatment SUVmax) / (posttreatment SUVmax).

RESULTS: The SDR was 13-85% in tumors and 4-100% in lymph nodes. No difference was seen in the SDR between the CRT and chemotherapy groups (p=0.957). Downstaging after induction therapy was seen in 28 cases (66.7%), and the treatment effect was Complete Response/Partial Response/Stable Disease/Progressive Disease = 0/37/5/0. A correlation of r=0.420 was seen between the shrinkage rate of the target lesions and the SDR. The SDR was significantly higher in the group with the higher histological treatment effects (64%) than in the group with the lower effects (39%; p=0.001). The SDR was significantly higher in the downstage group (59%) than in the non-downstage group (37%; p=0.031).

CONCLUSIONS: No difference in the SDR was seen by treatment method. A correlation was shown between the treatment success rate of the target lesions and the SDR, and the SDR were higher in cases with higher histopathological treatment effects and greater downstaging.

CLINICAL IMPLICATIONS: The SDR is thought to reflect the treatment effect and to be useful for preoperative evaluation following induction therapy.

DISCLOSURE: The following authors have nothing to disclose: Makoto Takahama, Ryoji Yamamoto, Hirohito Tada

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Osaka City General Hospital, Osaka, Japan
Chest. 2012;142(4_MeetingAbstracts):56A. doi:10.1378/chest.1388778

SESSION TYPE: Thoracic Surgery Posters I

PRESENTED ON: Wednesday, October 24, 2012 at 01:30 PM - 02:30 PM

PURPOSE: The purpose of this study is to evaluate the late imagistic and clinical features of the patients with a history of plombage thoracoplasty for tuberculosis (TB) admitted to our unit.

METHODS: Between 01.01.1990-01.01.2012 we admitted in our clinic a total number of 5 patients with a history of plombage thoracoplasty. The plombage was performed with: balls (2 cases), autologous rib (2 cases) and oil-filled bag (1case). All the innitial procedures were performed on other units or by other surgeons, plombage thoracoplasty being abandoned by our team. The interval between the plombage thoracoplasty and admittance to our unit ranged between 7 and 46 years (average 29).

RESULTS: 2 patients were admitted for complications related to the plombage thoracoplasty - recurrence and overinfection requiring reoperation (removal of the plombage material and thoracomyoplasty). One patient presented a contralateral empyema and two patients presented no thoracic complaints. The plombage material was obvious on both CXR and CT scans in all cases. At one year follow-up, the operated patients presented no recurrence and no significant thoracic complaints. One patient died of causes unrelated to the plombage thoracoplasty (myocardial infarction).

CONCLUSIONS: Late survivors of plombage thoracoplasty may be encountered in the current medical practice. They may present with complications related to plombage thoracoplasty or for other health problems.

CLINICAL IMPLICATIONS: Although plombage thoracoplasty is a hystorical procedure, doctors involved with the treatment of chest diseases should be familiar with the imagistic and clinical features of these procedures since they may meet late survivors with or without complications related to the plombage material.

DISCLOSURE: The following authors have nothing to disclose: Petre Vlah-Horea Botianu, Alexandru-Mihail Botianu

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University of Medicine and Pharmacy, Tirgu-Mures, Romania
Topics: thoracoplasty
Chest. 2012;142(4_MeetingAbstracts):57A. doi:10.1378/chest.1384599

SESSION TYPE: Thoracic Surgery Posters I

PRESENTED ON: Wednesday, October 24, 2012 at 01:30 PM - 02:30 PM

PURPOSE: To assess the HRQL in patients with early stage NSCLC undergoing Video Assisted Thoracoscopic (VATS) lobectomy.

METHODS: We performed a prospective study of NSCLC patients undergoing VATS lobectomy at our tertiary care, teaching center. Before surgery, baseline assessment of HRQL was captured using the SF-36, the EORTC QLQ30 and QLQ13 and the EQ-5D questionnaires. Post-operative assessment of HRQL was conducted at regular intervals (2, 4, 8 and 12 weeks) after surgery, using the same questionnaires administered at baseline. Changes in HRQL scores over the follow-up period were compared using paired t-test.

RESULTS: Between March and September 2011, 44 eligible patients were recruited into the study. The mean age was 65.1 (SD 8.7; range: 46-81) years; 24 (55%) were male. Tumor stage was IA in 55%, IB in 30%, IIA in 7%, IIB in 7% and IIIA in 2%. The median chest tube duration was 3 (mean 5, SD 3.9) days. The median length of stay was 5 (mean 6.1, SD 4.7) days. Three patients had conversion to thoracotomy and remained in the study. Two months after surgery, patients were still below their baseline HRQL measured by the EORTC QLQ 30 and QLQ13 in the following scales and symptoms: Global Health Status, Role Limitation - Physical, Dyspnea, Fatigue, Chest Pain and Shoulder Pain (p<0.05 for all). By three months after VATS lobectomy, patients experienced return to their baseline HRQL in 6 of 8 domains of the SF-36: Global Health, Bodily Pain, Physical Functioning, Social Functioning, Mental Health and Role Limitations - Emotional (p>0.05 for all). The EQ-5D questionnaire showed no significant difference.

CONCLUSIONS: While previous work have shown that HRQL after thoracotomy for lung cancer resection impairs patients’ HRQL for a period of six to twelve months, those undergoing VATS lobectomy regain most of their baseline HRQL in as soon as three months post operatively.

CLINICAL IMPLICATIONS: VATS lobectomy has a better impact on patients' HRQL, with most of the patients return to their baseline HRQL within 3 months after surgery, regardless of their length of stay and post-operatie complication.

DISCLOSURE: Sayf Gazala: Grant monies (from industry related sources): Johnson and Johnson research operational grant

Jeffery Johnson: Grant monies (from industry related sources): Johnson and Johnson research operational grant

Jim Kutsogiannis: Grant monies (from industry related sources): Johnson and Johnson research operational grant

Eric Bedard: Grant monies (from industry related sources): johnson and Johnson research operational grant

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University of Alberta, Edmonton, AB, Canada
Chest. 2012;142(4_MeetingAbstracts):58A. doi:10.1378/chest.1389476

SESSION TYPE: Thoracic Surgery Posters I

PRESENTED ON: Wednesday, October 24, 2012 at 01:30 PM - 02:30 PM

PURPOSE: Pleural lavage cytology (PLC) is the microscopic study of cells obtained from saline instilled into and retrieved from the chest cavity. However, this procedure is not necessary for the staging of lung cancer in the current TNM staging system. The aims of this study were to examine whether exfoliated cancer cells can be present in the pleural cavity with no pleural effusion, to determine independence as a prognostic marker and to characterize the impact of a positive result.

METHODS: Between 1995 and 2008, 1965 patients underwent surgical pulmonary resection for primary lung cancer without disseminated disease at our institute. Cytology of pleural lavage immediately after thoracotomy before any manipulation of the lung was examined in 812consecutive patients with lung cancer with no pleural effusion.

RESULTS: The results of the cytologic examination were divided into two categories, positive and negative PLC group. Papanicolaou classes I to IIIa were regarded as negative, classes IIIb, IV and V as positive. Of the 55 patients (6.8%) whose specimens were positive for PLC. Of the 55 patients in the positive PLC group, 47 (8.4%) had adenocarcinoma, with a significantly higher ratio of adenocarcinoma compared with the negative PLC group. Survival in the positive PLC group was significantly worse than in the negative PLC group (p = 0.001), especially in pathologic stage II (p = 0.001). We assume that the PLC positive cases have a T4 status. All PLC positive cases are reassigned Stage III. The result showed almost similar curves was shown between PLC negative Stage III and the adjusted PLC positive Stage III.

CONCLUSIONS: A positive PLC result was a strong unfavorable prognostic factor. PLC should be considered in all patients with early stage lung cancer suitable for resection.

CLINICAL IMPLICATIONS: We propose that positive PLC disease should be managed similarly to dissemination. That suggests it may be appropriate to upstage patients by 1 T category or consider as T4 disease.

DISCLOSURE: The following authors have nothing to disclose: Masatoshi Kakihana, Jitsuo Usuda, Naohiro Kajiwara, Tatsuo Ohira, Norihiko Ikeda

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Tokyo Medical University, Tokyo, Japan
Chest. 2012;142(4_MeetingAbstracts):59A. doi:10.1378/chest.1389744

SESSION TYPE: Thoracic Surgery Posters I

PRESENTED ON: Wednesday, October 24, 2012 at 01:30 PM - 02:30 PM

PURPOSE: To describe the incidence of pleural effusion (PE) after cardiac surgery requiring thoracocentesis and Video-Assisted Thoracoscopic Surgery (VATS) pleurodesis.

METHODS: All the patients undergoing cardiac surgery from June 2008 to November 2011 were retrospectively identified. Patients having pleural ultrasound (US), US-guided thoracocentesis or VATS pleurodesis for diagnosis or treatment of PE were recognized and their clinical records reviewed.

RESULTS: 2164 patients having cardiac surgery were identified. Pleural US for clinical or radiological suspicion of PE was performed 376 times (17%) in 242 patients (11%) to demonstrate the effusion; US-guided thoracocentesis was done in 68 patients (3.14%) for symptoms or for a large PE unlikely to resolve with medical treatment. After having at least two US-guided thoracocentesis, eight patients (0.36%) had recurrent PE and VATS pleurodesis was performed. 5/8 patients had coronary artery by-pass graft surgery while 3/8 patients had other cardiac procedures. The median elapsed time between the first thoracocentesis and VATS was 39.5 days (9-65.5 days). The mean number of US-guided drainage procedures in patients undergoing VATS pleurodesis was 3.5±1.2. Pleural fluids were exudates with high proportion of lymphocytes; the mean drained volume was 1144 ml. PE was left-sided in 5/8 patients; the indication for surgery was dyspnea in 7/8. VATS talc-pleurodesis was done in seven patients; one patient had a right VATS decortication and mechanical pleurodesis. No postoperative complications were observed. The median length of stay was 6 days (5-6 days). No PE recurrences were identified on follow-up. VATS pleural biopsies were done in 5/8. Pathology report showed chronic pleuritis with lymphocyte infiltration in all cases.

CONCLUSIONS: Although the presence of PE after cardiac surgery is a relatively common finding, the need of thoracocentesis is infrequent. Recurrent PE after cardiac surgery can be effectively treated by VATS pleurodesis with low morbidity or mortality.

CLINICAL IMPLICATIONS: Given the effectiveness and safety of VATS pleurodesis for the treatment of recurrent PE after cardiac surgery, its earlier use (after the second or even the first failed thoracocentesis) should be considered.

DISCLOSURE: The following authors have nothing to disclose: Sebastian Defranchi, Didier Bruno, Roberto Favaloro, Federico Zeppa, Alejandro Bertolotti

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Hospital Universitario Fundación Favaloro, Ciudad de Buenos Aires, Argentina
Chest. 2012;142(4_MeetingAbstracts):60A. doi:10.1378/chest.1389976

SESSION TYPE: Thoracic Surgery Posters I

PRESENTED ON: Wednesday, October 24, 2012 at 01:30 PM - 02:30 PM

PURPOSE: The aim of this study is to evaluate the possibilities and limitations of using muscle flaps for postoperative empyema after major thoracic procedures.

METHODS: Between 01.01.2003-01.01.2011 we used muscle flaps during major reoperations in 26 cases of postoperative empyema. The primary procedure was decortication - 14 cases (alone in 4 cases, associated with other procedures in 10 cases), pneumonectomy - 4 cases, lobectomy - 4 cases, non-anatomic resection - 5 cases and thoracoplasty - 1 case. The flaps were chosen according to the anatomy of the empyema and availability after the previous thoracotomy. In order to achieve complete obliteration we associated a topographic rib resection-ranges 1-6, with an average of 3,6/patient.

RESULTS: The following extrathoracic muscle flaps were used: serratus anterior 24 cases, latissimus dorsi 18 cases, pectorals - 9 cases, subscapularis - 4 cases, omentum - 1 case; intercostal flaps were also used in all cases. We encountered 1 postoperative death (4%). Local complications included empyema recurrence - 2 cases, tumoral recurrence - 1 case and minor skin necrosis - 1 case; we encountered no flap necrosis. Intensive care unit stay ranged between 1-9 days, with a median of 2 days and overall postoperative hospitalisation ranged between 8-87 days, with a median of 36 days. At late follow-up, we encountered in 4 patients (15%) a minor limitation of the shoulder mobility.

CONCLUSIONS: The use of the neighbourhood muscle flaps is always possible if major surgery for postoperative empyema is required. The main limitation is the damage resulted from the previous thoracotomy, making an associated limited thoracoplasty frequently necessary.

CLINICAL IMPLICATIONS: Muscle flaps are usefull in cases of postoperative empyema. Thoracic surgeons should be familiar with the techniques of mobilization and intrathoracic transposition of the muscle flaps.

DISCLOSURE: The following authors have nothing to disclose: Petre Vlah-Horea Botianu, Alexandru-Mihail Botianu

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University of Medicine and Pharmacy, Tirgu-Mures, Romania
Chest. 2012;142(4_MeetingAbstracts):61A. doi:10.1378/chest.1389998

SESSION TYPE: Thoracic Surgery Posters I

PRESENTED ON: Wednesday, October 24, 2012 at 01:30 PM - 02:30 PM

PURPOSE: The objective of this paper is to evaluate the results of surgery for pulmonary aspergilloma.

METHODS: We performed a retrospective study on 35 patients operated in our unit between 01.01.1985-01.01.2011 for pulmonary aspergilloma. All the patients were referred for surgery after failure of the medical treatment and received postoperative treatment with specific antifungal drugs (amphotericine, voriconasole). Most patients (32 out of 35) presented a history of tuberculosis (TB) with the aspergilloma developing on TB lesions. Surgery consisted in lung resection in 28 cases (lobectomy - 5 cases, non-anatomic - 23, with 6 cases associating an applatisation-plication of the cavity) and thoracomioplasty in 7 cases. The following main parameters were followed: mortality, morbidity, reoperations, hospitalisation - intensive care unit (ICU) and overall, status at one year after surgery.

RESULTS: Overall mortality was 5,7% (2 patients). We encountered 3 residual suppurated cavities requiring a major reoperation (open-window or thoracoplasty). ICU stay after surgery ranged between 1 and 6 days, with an average of 2 days. Postoperative hospitalisation ranged between 10 and 87 days, with an average of 27 days. At one-year follow-up (clinical, sputum bacteriology, chest X-ray +/- CT scan) we have encountered no recurrence, with two deaths not related to the thoracic problems.

CONCLUSIONS: Surgery remains an option for patients with aspergilloma not responding to medical treatment. In selected cases, both lung resection and thoracomioplasty may give good results.

CLINICAL IMPLICATIONS: Surgical treatment for aspergilloma remains a challenge due to the technical difficulties and the poor biological status of the patients.

DISCLOSURE: The following authors have nothing to disclose: Alexandru-Mihail Botianu, Petre Vlah-Horea Botianu

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University of Medicine and Pharmacy, Tirgu-Mures, Romania
Chest. 2012;142(4_MeetingAbstracts):62A. doi:10.1378/chest.1391831

SESSION TYPE: Thoracic Surgery Posters I

PRESENTED ON: Wednesday, October 24, 2012 at 01:30 PM - 02:30 PM

PURPOSE: Hemidiaphragm paralysis can result in significant disability. Short term results for minimally invasive surgical diaphragm plication appear promising, but the durability of the operation is not defined. We present the mid term results of a minimally invasive approach to diaphragm plication.

METHODS: We performed a retrospective review of all symptomatic patients operatively treated for diaphragm paralysis or eventration at our institution from April 2007 through December 2009. Patients treated thoracoscopically or laparoscopically were included. Pulmonary function testing was performed preoperatively, postoperatively and at yearly intervals with change assessed over time. Symptomatic impact was assessed by administration of the St George’s Respiratory Questionnaire (SGRQ) at corresponding time intervals.

RESULTS: A total of 11 patients (6 left side, 5 right side) underwent laparoscopic or thoracoscopic diaphragm plication during the study period. Postoperative improvement was seen in all measused pulmonary function variables (upright FVC 54.7% preoperative vs 58.3% postoperative and 49.3% vs 55.9% supine; FEV-1 48.7% vs 52.2%; maximal FIF 99% vs 105.2%). Mean upright FVC increased from a baseline value of 54.7 % predicted to 60.2% at one year (p=0.08) and 57.5% at 2 years. In the supine position, a similar trend was seen and remained significant at 2 years (58.3% p=0.02). A clinically important increase from baseline FEV-1 was seen at 1 year (56.8%) and remained at 2 years (51.2%). The mean baseline SGRQ score was 62.6 and improved over time with a reduction in SGRQ of 24.1 points postoperatively, 32.3 at 1 year and 12.8 at 2 years. A change in SGRQ of ≥4 points is considered clinically important. No immediate or late operative complications were seen.

CONCLUSIONS: Minimally invasive diaphragm plication can be performed safely and results in a durable improvement in pulmonary function. Most importantly, improvement in patient reported symptoms is also seen 2 years following surgical intervention. Further long-term follow-up is needed to confirm these findings in a larger patient cohort.

CLINICAL IMPLICATIONS: Operative diaphragm plication should be considered for symptomatic patients with hemidiaphragm paralysis or eventration.

DISCLOSURE: The following authors have nothing to disclose: David Odell, Jonathan D'Cunha, Teri Kast, Michael Maddaus, Raphael Andrade

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University of Minnesota, Minneapolis, MN
Chest. 2012;142(4_MeetingAbstracts):63A. doi:10.1378/chest.1380697

SESSION TYPE: Thoracic Surgery Posters I

PRESENTED ON: Wednesday, October 24, 2012 at 01:30 PM - 02:30 PM

PURPOSE: Acute massive pulmonary embolism is a rare life-threatening condition. There is no consensus regarding the best method for prompt treatment, which includes heparin, thrombolytic agents, catheter-based embolectomy, or surgical embolectomy. This study retrospectively reviews emergency surgical pulmonary embolectomy in a referral hospital setting.

METHODS: Between November of 2008 and October of 2011, 7 patients (4 male, age range 30-72 years) underwent emergency surgical embolectomy for massive pulmonary embolism. The indications for surgical intervention were (1) contraindication to thrombolysis (4/7 [57.1%]) and (2) right ventricular dysfunction (2/7 [28.6%]). Preoperatively, 2 patients were in cardiogenic shock and 1 patient in cardiac arrest. All patients underwent operations with hypothermic arrest cardiopulmonary bypass.

RESULTS: There were no operative deaths, but 2 patients died in the hospital on postoperative days 9 and 20, one patient had preoperative cardiac arrest and the other patient had preoperative cardiogenic shock. One late death occurred because of an underlying metastatic cancer. Pre and postoperative echocardiographic pressure measurements demonstrated the reduction of the pulmonary hypertension to half of the pre-surgical pressure values or less.

CONCLUSIONS: The results of emergent pulmonary embolectomy are encouraging particularly among patients without cardiogenic shock or arrest. A surgical approach is an excellent option for patient with massive pulmonary embolism and outcomes show minimal mortality and morbidity. Immediate surgical approach also quickly decreases the right ventricular after load and improves right ventricular function by reducing the pulmonary pressure by more than half.

CLINICAL IMPLICATIONS: It should be noted that surgical embolectomy should not be reserved as a last resort option. Rather, a surgical approach should be considered in patients with right ventricular dysfunction that is an early sign of impending hemodynamic collapse. These patients are best managed with a multispecialty approach including pulmonary, cardiology, and cardio-thoracic surgical specialists. Emergent risk stratification with CT angiogram, bio-markers, and ECHO can result in improved pulmonary patent vasculature, improved right heart function, and improved patient survival.

DISCLOSURE: The following authors have nothing to disclose: David No, Christine No, Kevin Casey, Gerald Tracy

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The Commonwealth Medical College, Scranton, PA
Chest. 2012;142(4_MeetingAbstracts):64A. doi:10.1378/chest.1388272

SESSION TYPE: Thoracic Surgery Posters I

PRESENTED ON: Wednesday, October 24, 2012 at 01:30 PM - 02:30 PM

PURPOSE: Renal dysfunction is one of major complications after cardiovascular surgery. Age, cardiopulmonary bypass (CPB) and other factors may affect the postoperative renal function. Changes of renal function before and after the surgery were examined.

METHODS: Data from 266 patients who received 24 hours creatinine clearance test (Ccr)(L/day) before the cardiovascular surgery between October 2003 and December 2011 were reviewed. Preoperative serum creatinine (Cr)(mg/dl), Ccr, postoperative peak Cr (pCr)(mg/dl), and the period (POD) between the operation and day of pCr, the ratio of pCr/Cr were analyzed. Patients were divided into two groups by Ccr, Cr(H)(Cr>=70) and Cr(L)(Cr<70), and also, into two groups with or without CPB (CPB(+)and CPB(-)). Patients were divided into four groups by age, A50 (<60), A60 (60-69), A70 (70-79) and A80 (80<=).

RESULTS: They were 167 males and 99 females, and the mean age was 67.6 years old. The average Ccr, Cr, pCr, pCr/Cr and POD (day) were 75.3, 1.00, 1.36, 1.35 and 3.3, respectively, and negative correlation was observed between Ccr and Cr. Those were 101.1, 0.77, 0.95, 1.25 and 2.9 in Ccr(H)(N=132), 49.9, 1.23, 1.76, 1.45 and 3.8 in Ccr(L)(N=134), respectively. Those were 77.8, 0.95, 1.35, 1.42 and 2.8 in CPB(+)(N=136), and 72.8, 1.05, 1.38, 1.29 and 3.9 in CPB(-)(N=130), respectively. Renal function deteriorated in elder group, and Cr and pCr were getting higher than younger group. Although no significant difference of Ccr and Cr were observed between CPB(+) and CPB(-), pCr/Cr of CPB(+) was significant higher than that of CPB(-).

CONCLUSIONS: Attention should be paid to patients whose preoperative Cr were less than 70 even though Ccr were within normal. pCr/Cr level in CPB(+) was higher than that in CPB(-), suggesting that CPB could be affected postoperative renal function. The preoperative renal function in elder patients was worse than younger patients, postoperative renal function got worse.

CLINICAL IMPLICATIONS: In addition, diabetes might affect renal function, and attention should be paid after the operation in patients with complications

DISCLOSURE: The following authors have nothing to disclose: Katsuhito Teranishi

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Chubu Rosai Hospital, Nagoya, Japan
Chest. 2012;142(4_MeetingAbstracts):65A. doi:10.1378/chest.1367066

SESSION TYPE: Thoracic Surgery Posters II

PRESENTED ON: Wednesday, October 24, 2012 at 01:30 PM - 02:30 PM

PURPOSE: Thoracoscopy offers great advantages when compared with open surgery in terms of postoperative pain and pulmonary complications. Thoracoscopy is safe and feasible with minimal morbidity. The purpose of this study is to evaluate the indications, surgical procedures, complications, and failure rates of VATS in the diagnosis and treatment of intrathoracic diseases.

METHODS: One hundred seventy consecutive patients, 112 men and 58 women, with age ranging from 17 to 75 years (mean 45.7 years), underwent one hundreds seventy diagnostic, therapeutic and diagnostic & therapeutic VATS procedures. Indications included recurrent or persistent pneumothorax (n = 50 patients), empyema thoracis (20), solitary pulmonary nodules (23), diffuse lung disease (12), undiagnosed pleural effusions(40), mediastinal masses or cysts(20),bronchiectasis with hemoptysis(5).

RESULTS: Of the 170 VATS procedures, 157 (92.4%) procedures were successfully performed. Thirteen patients (7.6%) requried conversion to thoracotomy due to bleeding in 2 who had excision lung bleb, extensive adhesion in 2 with chronic empyema thoracis and unlocated lesion in 2 with solitary pulmonary nodule (SPN).There were 19 (11.2%) nonfatal postoperative complications: prolonged air leak for more than 5 days was seen in 8 patients. This complication occurred in 3 patients with spontaneous pneumothorax and 3 patients with empyema. Wound infection occurred in 3 patients. VATS in diagnostic procedures were effective in 91% (40 of 44 patients) and the procedures were 17 wedge excision for interstitial lung disease & (SPN), 19 pleural biopsies, and 8 biopsies for mediastinal tumors. Seventy five therapeutic procedures were effective in 70 patients (93.3 %) (71 of 75 patients).The success rate of the diagnostic & therapeutic procedures was 92.2% (47 of 51 patients) .Only small doses of analgesics were needed. There was no intraoperative mortality. The mean operative time was 71 minutes, The overall mean duration of chest tube drainage was 2.5 days and the average postoperative hospital stay was 5.1 days for successful VATS group.

CONCLUSIONS: VATS is a safe and effective method for diagnosis and treatment of intrathoracic diseases. Patients had benefit in reduced postoperative pain, short hospitalization, short recovery times and good cosmetic result.

CLINICAL IMPLICATIONS: VATS valuable is in diagnosis & treatment of lung, mediastinal & pleural lesions and spare patients hazard of thoracotomy.

DISCLOSURE: The following authors have nothing to disclose: Hamdy Mahmoud, Ayman Abdel ghaffar

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Sohag University-Sohag Faculty of Medicine, Sohag-Elmaragha-Nagecc Elhakim, Egypt
Chest. 2012;142(4_MeetingAbstracts):66A. doi:10.1378/chest.1381714

SESSION TYPE: Thoracic Surgery Posters II

PRESENTED ON: Wednesday, October 24, 2012 at 01:30 PM - 02:30 PM

PURPOSE: To describe the experience in the management of hepatic hydrothorax considering and comparing thoracoscopic and slurry pleurodesis.

METHODS: Retrospective review of medical charts of consecutive patients with diagnosis of hepatic hydrothorax.

RESULTS: 55 patients with hepatic hydrothorax diagnosis were found. 20 patients underwent surgical treatment and pleurodesis. There were 13 women. All patients were symptomatic and the principal symptom was dyspnea (100%). The pleural effusion was right sided in 75% of cases. Most patients had a pleural effusion greater than 50% (18 patients) and 9 patients had a massive effusion. According to fluid biochemical profile 80% were compatible with trasudate and 4 patients had an exudate and met the criteria for bacterial spontaneous empyema. Related to hepatic function 20% of patients had Child-Pugh A status; 10 patients (50%) B satus and 6 patients had Child-Pugh C status. There were two treatment groups. Gropup 1: chest tube and slurry talc/iodine pleurodesis; (8 patients) Group 2 thoracoscopy and talc poudrage (12 patients). The terapeutic response was as follows: 5 patients (25%) had a complete response; 7 patients (35%) parcial response and 5 patients had no response to treatment and persist with effusion and symptoms. In three cases no evaluation was possible due to mortality within 48 hrs in two patients and early transfer in one case. Morbidity was 40% (8 patients). No operatory mortality was present and the hospital mortality was 40% related to hepatic insufficiency.

CONCLUSIONS: Hepatic hydrothorax is a therapeutic challenge. However in 60% of cases a good response to treatment is present. The mortality is high but is not related to therapeutic procedures.

CLINICAL IMPLICATIONS: Surgical management of hepatic hydrothorax is possible by means of pleurodesis. Good response to treatment was found in our experience.

DISCLOSURE: The following authors have nothing to disclose: Juan Jacinto, Patricio Santillan-Doherty, Luis Argote-Greene, Rocio Carrera-Ceron, Julio Herrera-Zamora

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Angeles de las Lomas Hospital, Huixquilucan Mex, Mexico
Chest. 2012;142(4_MeetingAbstracts):67A. doi:10.1378/chest.1385667

SESSION TYPE: Thoracic Surgery Posters II

PRESENTED ON: Wednesday, October 24, 2012 at 01:30 PM - 02:30 PM

PURPOSE: In 2008 in Russia 12275 patients were submitted to thoracic surgery for pulmonary tuberculosis. Segmentectomies made up 61,7% of all operations and lobectomies made up 15,3% of the operations. The aim of this study was to assess long-term results of lung resection for pulmonary tuberculosis.

METHODS: We investigated quality of life (QoL) and pulmonary function in 76 patients after lung resection. Of these 76 patients, 37 underwent single lobectomy (group L) and 39 underwent segmentectomy (group S). All postoperative examinations were performed more than one year after surgery. QoL was studied with St. George's Respiratory Questionnaire (SGRQ) and UCSD Shortness of Breath Questionnaire (SOBQ). Pulmonary function was studied by spirometry and plethysmography.

RESULTS: In patients in group S and group L, respectively, age was 39,9±11,6 years and 49,1±14,1 years (respectively, p<0.05); body mass index was 24,5±3,9 kg/m2 and 23,7±4,2 kg/m2 (p>0.05). In patients in group S and group L, respectively, FVC were 103,8±13,6% and 102,9±15,3% (p>0.05); FEV1 were 91,3±16,7% and 84,5±16,5% (p>0.05); FEV1/FVC were 0,74±0,13 and 0,68±0,13 (p>0.05); PEF were 88,9± 24,0% and 75,2± 19,4% (p<0.05); TLC were 99,4±10,4% and 98,3±12,6% (p>0.05); FRC were 110,3±26,6% and 109,7±27,7% (p>0.05); IC were 89,5±17,5% and 89,6±18,8% (p>0.05); RV/TLC were 0,26±0,83 and 0,32±0,12 (p<0.05); IC/TLC were 0,45±0,10 and 0,43±0,09 (p>0.05); Symptoms SGRQ scores were 16,4±17,8% and 31,5±22,6% (difference was 15,1 points, p<0.01); Activity SGRQ score were 16,5±17,2% and 30,6±19,3% (difference was 14,1 points, p<0.01); Impact SGRQ scores were 8,8±14,5% and 17,5±15,8% (difference was 8,7 points, p<0.05); Total SGRQ score were 12,2±15,0% and 23,7±16,0% (difference was 11,5 points, p<0.01); SOBQ scores were 7,1±9,3% and 16,1±15,2% (difference was 9,0 points; p>0.05). In group S airway obstruction (FEV1/FVC <0.7) was 28,2% and in group L airway obstruction was 43,2% (OR 1.94; CI 95% 0.75 to 5.03; p>0,05). In groups S and L low pulmonary function (FEV1<80%) was 12,8% and 32,4% (OR 3.26; CI 95% 1.02 to 10.45; p>0,05).

CONCLUSIONS: QoL in patients after lobectomy was significantly worse than in patients after segmentectomy, though the results of pulmonary function were almost the same.

CLINICAL IMPLICATIONS: The patients after lobectomy need more active treatment including pulmonary rehabilitation.

DISCLOSURE: The following authors have nothing to disclose: Mikhail Chushkin, Oleg Ots, Sergey Mandrykin, Eduard Tikhokhod, Sergey Smerdin

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Research Institute of Phthisiopulmonology, Moscow, Russian Federation
Chest. 2012;142(4_MeetingAbstracts):68A. doi:10.1378/chest.1388989

SESSION TYPE: Thoracic Surgery Posters II

PRESENTED ON: Wednesday, October 24, 2012 at 01:30 PM - 02:30 PM

PURPOSE: Evaluate the effectiveness of the new system of sternal stabilization named ZipFix® (Synthes) similar for the use of cable ties in poly-ether-ether-ketone (PEEK), biocompatible and radiolucent (no-scattering Rx standard, CT and MRI). The aim of this study is, therefore, consisted in bringing the benefits in terms of results in the short and long term duration/cost of the procedure and hospital stay, functional restoration even in patients at risk of dehiscence (osteoporosis, kidney failure, diabetes, COPD, hemorrhage, reoperation, mechanical ventilation, tracheotomy, radiation, obesity).

METHODS: The cable ties are in large base of contact with the bone and equipped with needle plate and removable chamfer steel; were implanted through the intercostal space and in the parasternal in number of 3-5 from I to V space, according to the situation. Anatomically, the condition being treated or the preferences of the surgeon, with an mean duration of implant procedure about 16 minutes. Throughout the year 2011 the system was used with PEEK cable ties only for the synthesis of longitudinal median sternotomy in 6 patients.

RESULTS: Short-term results: chest pain treated with 30 mg of ketorolac for three times a day to the removal of any drainage, absence of superficial and deep infections, bleeding (0% of cases), lack of early dehiscence and instability; mean duration of implant procedure 16 minutes. For long-term results: chest pain lag for the first 3 months and controlled effectively by administering paracetamol (500 mg in 80% of cases), absence of dehiscence, instability/deformation and chronic infections; excellent aesthetic results in 100% of cases, functional restoration and return to work after 40 days.

CONCLUSIONS: Furthermore, this system can be combined with other methods of fixing sternal in relation to the choices of the surgeon and requires a rapid learning curve thanks to the considerable maneuverability and ease of installation.

CLINICAL IMPLICATIONS: Due to the nature and mechanical performances of the polymeric material they are made of the cable ties ZipFix ® are definitely innovative and advantageous compared to other standard methods of sternal osteosynthesis.

DISCLOSURE: The following authors have nothing to disclose: Cosimo Lequaglie, Gabriella Giudice, Rita daniela Marasco, Aniello Della Moret

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IRCCS-CROB Centro di Riferimento Oncologico Basilicata, Rionero in Vulture PZ, Italy
Chest. 2012;142(4_MeetingAbstracts):69A. doi:10.1378/chest.1389386

SESSION TYPE: Thoracic Surgery Posters II

PRESENTED ON: Wednesday, October 24, 2012 at 01:30 PM - 02:30 PM

PURPOSE: Non-small cell lung cancer (NSCLC) is a disease of the elderly, but many patients over 80 are not considered surgical candidates based on age and underlying co-morbidities. Patients may choose alternative management options such as chemotherapy with radiation or palliative care. These patients may benefit from operations such as a VATS lung resection or a traditional thoracotomy. This report describes our experience with minimally invasive and open lung resections in octogenarians for NSCLC.

METHODS: A retrospective chart review was performed on 35 patients over 80 years old who underwent a VATS or open lobectomy or segmentectomy for NSCLC since 2002. Patients were evaluated by age, tumor stage, length of stay and complication rates. Operations performed were: right upper lobectomy-17, right middle lobectomy-1, right lower lobectomy-7, left upper lobectomy-4, left lower lobectomy-6, RLL superior segmentectomy-1.

RESULTS: Mean age was 83.2±2.5 (range 80-90). Out of 35 patients, 17 underwent a VATS procedure and 18 underwent an open procedure. Average length of stay was 9.9±9.3 (range 3-47). There were 4 total operative mortalities (11.4%), 3 underwent an open procedure. No complications occurred in 7/30 (23%) patients. Complications included atrial fibrillation-10; prolonged airleaks-3; urinary retention-2; pneumonia-2; subcutaneous emphysema-1; cerebral vascular accident-1; ARDS-1; PE-1; atelectasis-1. Stages included: IA-4; IB-15; IIB-4; IIIA-10.

CONCLUSIONS: Octogenarians with stage I-III NSCLC may benefit from minimally invasive or open lung resections. These operations were associated with minor complications, including atrial fibrillation, prolonged air leaks, urinary retention and pneumonia. Serious complications included ARDS and death. Post-operative length of stay is highly variable and dependent on the type of operation and post-operative complications.

CLINICAL IMPLICATIONS: Patients over 80 with resectable NSCLC may benefit from a VATS lobectomy over an open procedure based on operative complications and length of stay.

DISCLOSURE: The following authors have nothing to disclose: Chad Hall, Rudy Lackner, Karin Trujillo

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University of Nebraska Medical Center, Omaha, NE
Chest. 2012;142(4_MeetingAbstracts):70A. doi:10.1378/chest.1389992

SESSION TYPE: Thoracic Surgery Posters II

PRESENTED ON: Wednesday, October 24, 2012 at 01:30 PM - 02:30 PM

PURPOSE: The purpose of this paper is to evaluate the indications and results of one-stage bilateral thoracotomy approach in an unit with no lung transplantation programme.

METHODS: Between 01.01.1985-01.01.2012 our team has performed one-stage bilateral thoracotomies in a total number of 20 patients. Indications for this approach included: hydatid disease (one including a right thoracophrenotomy to approach a hepatic hydatid cyst) - 9 pts., thoracic trauma - 2 pts., bilateral metastases - 2 pts., bilateral empyema - 2 pts., bilateral blebs - 2 pts., primary lung cancer + contralateral metastase - 1 pt., bilateral hidro-pneumothorax - pleural carcinomatosis and trapped lung - 1 pt., bilateral metallic foreign bodies (suicide attempt) - 1 pt. In other 4 cases where this approach was planned, the second procedure was postponed at the request of our anesthesia colleagues (patients not included in this study). All the procedures were performed by the same team.

RESULTS: We encountered no mortality. None of the patients required prolonged postoperative mechanical ventilation. One patient with bilateral empyema developed a residual cavity that eventually required a thoracomyoplasty procedure. Intensive care unit stay ranged between 1 and 5 days, with a median of 2 days. Overall postoperative hospitalization ranged between 12 and 67 days, with a median of 19 days.

CONCLUSIONS: For patients with bilateral thoracic diseases one stage bilateral thoracotomy is a good option. Carefull selection of the patients allows a low mortality and morbidity.

CLINICAL IMPLICATIONS: One-stage bilateral thoracotomy may be performed for a wide range of diseases, not only for lung transplantation and lung volume reduction surgery. The major advantages are functional one, psychologic and echonomical - reduction of costs to almost one half.

DISCLOSURE: The following authors have nothing to disclose: Alexandru-Mihail Botianu, Petre Vlah-Horea Botianu

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University of Medicine and Pharmacy, Tirgu-Mures, Romania
Topics: thoracotomy
Chest. 2012;142(4_MeetingAbstracts):71A. doi:10.1378/chest.1389487

SESSION TYPE: Thoracic Surgery Posters II

PRESENTED ON: Wednesday, October 24, 2012 at 01:30 PM - 02:30 PM

PURPOSE: Thoracoscopic wedge resection using three ports is the technique of choice for spontaneous pneumothorax or other lung lesions needed tissue confirmation. A few publications describing the uniportal thoracoscopic surgery an alternative to conventional three-port surgery have been reported. We herein introduce uniportal thoracoscopic wedge resection technique using a spinal needle.

METHODS: Between March 2011 and March 2012, 56 patients were enrolled. Only one incision (1.5~2.0 cm long) is placed in mid-axillary line of 5th~7th intercostal space according to the location of target lesions. A 5 mm 30° thoracoscope and a 5 mm grasper to hold target lesions were inserted into pleural cavity through the incision. And then a 20 gauge spinal needle bended about 90° was inserted into pleural cavity through mid- or anterior axillary line of 3rd~5th intercostal space. The target lesion was hooked by spinal needle and grasper was taken out of pleural cavity. The wedge resection was performed with roticulating stapler (endo-GIA, Covidien). We covered apex including the stapled line with fibrin glue and Neoveil® sheet additionally in patients with spontaneous pneumothorax. A 24 French chest tube was positioned through the incision.

RESULTS: Patients included 35 men and 21 women with mean age of 37 years (range 15~72). The surgical indications were 34 patients of primary spontaneous pneumothorax and 22 patients of other disease (primary lung cancer 5, metastatic lung cancer 3, interstitial lung disease 3, organizing pneumonia 2, fibrotic granuloma 2, tuberculosis 2, septic emboli 1, pulmonary sarcoidosis 1, chondroid hamartoma 1 and intrapulmonary LN 1). The mean operative time was 38 minutes (range 20~90). Neither mortality nor major morbidity was observed. The median chest drain duration and hospital stay were 2 days (range 1~3) and 3 days (range 2~5) in 35 patients with primary spontaneous pneumothorax.

CONCLUSIONS: Only 5 mm scope and stapler are inserted through a 1.5~2.0 cm incision during stapling in uniportal thoracoscopic wedge technique by use of a spinal needle to replace a grasper. We suggest that this technique is simple and easy to perform and may applicable to both spontaneous pneumothorax and other peripheral lung lesions needed tissue confirmation.

CLINICAL IMPLICATIONS: Uniportal thoracoscopic wedge resections of lung by use of a spinal needle is a simple, easy and cosmetic technique applicable to both spontaneous pneumothorax and other peripheral lung lesions needed tissue confirmation.

DISCLOSURE: The following authors have nothing to disclose: Cheonwoong Choi, Dae Hyun Kim

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Kyung Hee University Hospital at Gangdong, Seoul, Republic of Korea
Chest. 2012;142(4_MeetingAbstracts):72A. doi:10.1378/chest.1390392

SESSION TYPE: Thoracic Surgery Posters II

PRESENTED ON: Wednesday, October 24, 2012 at 01:30 PM - 02:30 PM

PURPOSE: Current smoking increases the risk of perioperative complications (especially respiratory failure and bronchial stump breakdown) in patients undergoing pneumonectomy, but has not clearly been shown to significantly increase operative risk in lesser procedures. Further, no data on the relative risk of thoracoscopic resections in patients who smoke and who do not has been reported. We report a prospective comparison of the perioperative risk and mortality between non-smoking and smoking patients undergoing lung resections.

METHODS: All our patients undergoing thoracic surgery were questioned about their smoking history and blood tests obtained for carboxyhemoglobin (CBH). Patients were considered smokers if they had smoked within two weeks of surgery or if CBH was elevated. Standard demographic data were collected, as was length of stay, perioperative complications (life-threatening, major, and minor), perioperative mortality and three year survival. Means were compared using student’s t test, and proportions using chi-square. Standard significance parameters were used.

RESULTS: 168 patients (60 smokers and 108 non-smokers) over two years underwent resection (wedge resection, segmentectomy, or lobectomy). No significant differences were found in the ages (smokers=61.1 years, nonsmokers=66.0), nor any significant demographic data (fraction of patients undergoing wedge resections, segmentectomies, or lobectomies, nor the fraction of men and women). The non-smokers did have more life-threatening complications (LTC) (Two versus six, p=0.04941), but no differences were seen in the overall incidence of complications (p=0.96). Further, no difference was seen in the perioperative mortality (no operative mortality in either group in this cohort). Finally, no difference in three year survival between smokers and non-smokers was seen.

CONCLUSIONS: Our data demonstrate that pre-operative smoking in patients undergoing thoracoscopic resections increases perioperative risk but does not increase perioperative mortality. Further, it did not affect short-term survival. These data suggest that resection can be planned in most smoking patients, as long as pneumonectomy is not expected.

CLINICAL IMPLICATIONS: Smoking patients who develop lung cancer can safely undergo resection if resection less than pneumonectomy is planned.

DISCLOSURE: John Roberts: Consultant fee, speaker bureau, advisory committee, etc.: Product development with Medtronic, Consultant fee, speaker bureau, advisory committee, etc.: Faculty instructor with Ethicon

The following authors have nothing to disclose: Timothy Roberts, Aravindhan Sriharan

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The Surgical Clinic, Sarah Cannon Cancer Center, Nashville, TN
Chest. 2012;142(4_MeetingAbstracts):73A. doi:10.1378/chest.1389417

SESSION TYPE: Thoracic Surgery Posters II

PRESENTED ON: Wednesday, October 24, 2012 at 01:30 PM - 02:30 PM

PURPOSE: To evaluate pulmonary function tests and blood gas analysis in patients with thoracic wall surgical stabilization for flail chest.

METHODS: 40 patients (30 men, 10 women; mean age 42.6 years) with antero-lateral flail chest (≧4 ribs fractured at ≧2 sites) were fulfilled the inclusion criteria and underwent surgical stabilization using metallic reconstruction plates. Clinical assessment, pulmonary function testing and blood gas were performed at 3 months following surgery. 10 patients couldn't able to perform pulmonary function because of either unstable or uncooperative.

RESULTS: Indications for surgical fixation were as follow: 10 patients required thoracotomy because of associated thoracic injuries; 15 non-intubated patients had antero-lateral flail chest; 15 patients without pulmonary contusion presented with impaired pulmonary function despite a few days (median 3 days) required (early surgical stabilization). There was no 30-day and 3 month mortality for the surgically treated patients. The median intensive care unit stay was 4.5 days. Infectious complications occurred in 5 % (2/40 patients). A satisfactory stabilization of the chest wall was obtained in all surgically treated patients. There were statistically significant difference in Pao2 (62.2± 8.3& 97.6±6.4), Paco2 (38.1±9.3& 32.4±8.4) and So2 (89.2%±1.4& 98.4±1.6) with P value <0.001 respectively. Improvement of pulmonary function test was significant in FVC (69.28±5.9& 78.55±5.5), FEV1 (68.07±4.7&78.97±3.9) FEV1/FVC ratio (98.25±9.3&100.53±6.9) and PEF (72.68±4.7& 80.23±4.1) with p value 0.001, 0.001, 0.08, 0.001 respectively.

CONCLUSIONS: surgical stabilization of flail chest with metallic plates is a safe and effective therapy in properly selected patients. These Patients had a significantly smoother course during the intensive care unit and hospital stays, had a significantly decreased rate of complications, and had almost no residual chest wall deformity.

CLINICAL IMPLICATIONS: Surgical stabilization may provide an early restoration of chest wall contour and result in a significant reduction in the duration of ventilatory support. Long-term postoperative pulmonary function seems to be better preserved after surgical stabilization.

DISCLOSURE: The following authors have nothing to disclose: Mohamed Badawy, Karam Moslam

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Qena Faculty of Medicine, Luxor, Egypt
Chest. 2012;142(4_MeetingAbstracts):74A. doi:10.1378/chest.1388416

SESSION TYPE: Thoracic Surgery Posters II

PRESENTED ON: Wednesday, October 24, 2012 at 01:30 PM - 02:30 PM

PURPOSE: Data on stage-specific outcomes following video-assisted thoracoscopic surgery (VATS) lobectomy for non-small cell lung cancer (NSCLC) is underreported. This study evaluated the midterm results of patients who underwent VATS lobectomy for resection of primary NSCLC and identified outcomes by stage groups.

METHODS: From January 2006 to December 2011, 174 patients (mean 66 years, range 32 to 95) with NSCLC underwent VATS lobectomy (pathologic Stage I 69%(120), Stage II 14%(25), Stage III 14%(24) and Stage IV 3%(5); p<0.001). Patients were identified from a retrospective review of a prospectively-maintained database. Multivariable analysis was used to identify predictors of postoperative recurrence and poor survival.

RESULTS: Thirty-day mortality was 0%. Postoperative chemotherapy and or radiotherapy treatment were not routinely administered in patients with stage I disease (6%(7), but administration increased with stage: 48%(12), 33%(8) and 80%(4) for stages II to IV, respectively (p<0.001). Recurrence-free survival was stage-dependent: 88%,68%,68%,and 56% at 1 year, and 78%,48%,46%, and 56% at 2 years for stages I to IV, respectively (p<0.01). However, overall survivals were similar (95%, 95%, 95%, and 100% at 1 year; 91%, 77%%, 69%, and 75% at 2 years; 82%,77%,69%, and 75% at 3 years for stages I to IV, respectively (p=0.28). Recurrence was more common in stages I and III patients with higher Charlson Comorbidity Index scores (CCI) (p< 0.001 and p< 0.05, respectively). Stage II patients with inferior American Society of Anesthesiologist scores (p<0.05) and larger tumors (mean 2.9 cm) (p<0.05) had higher recurrence rates. In stage I and III patients, survival was negatively associated with higher CCI (p< 0.001 and p< 0.05, respectively), development of recurrence (p< 0.001 and p< 0.05, respectively), and with worse Zubrod scores in stage III patients (p<0.05) only.

CONCLUSIONS: VATS lobectomy for primary lung cancer results in excellent midterm outcomes. Recurrence-free survival was stage-dependent, with the recurrence risk within stages impacted by patient-related factors and tumor size; however, equivalent overall 3-year survival was observed for all stage groups.

CLINICAL IMPLICATIONS: This study suggests patient characteristics, tumor size and stage all influence the recurrence after VATS lobectomy in patients with NSCLC.

DISCLOSURE: The following authors have nothing to disclose: Virna Sales, Ann Traynor, Tien Hoang, Toby Campbell, George Cannon, Tracey Weigel

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Department of Surgery, Section of Thoracic Surgery, Division of Cardiothoracic Surgery, University of Wisconsin Carbone Cancer Center, UW-Madison School of Medicine Public Health, Madison, WI
Chest. 2012;142(4_MeetingAbstracts):75A. doi:10.1378/chest.1364999

SESSION TYPE: Cardiac Surgery Posters

PRESENTED ON: Wednesday, October 24, 2012 at 01:30 PM - 02:30 PM

PURPOSE: To review our experience of surgical repair of post-infarction ventricular septal rupture (VSR) and analyse the outcomes and prognostic factors associated with this condition.

METHODS: In a retrospective review from January 1999 to December 2011, 38 patients underwent VSR repair at our tertiary referral centre.

RESULTS: Mean age was 65.7 ± 9.4 years (45 - 83). Male patients accounted for 52.6% of cases. The VSR location was anterior in 28 patients (73.7%) and posterior in 10 patients (26.3%). The median interval between myocardial infarction and septal rupture was 1 day (1, 4). Pre-operative intra-aortic balloon pump (IABP) counter-pulsation was used in 37 patients (97.8%). Coronary angiography was performed in 36 patients (94.7%). A patch repair technique was used in 35 patients (92.1%). Median aortic cross clamp time was 79 minutes (62.8, 108.0). Coronary artery bypass grafting (CABG) was performed in 19 patients (50%), with a mean of 1.5 ± 0.7 distal anastomoses. Operative mortality within 30 days of surgery was 39.5%, 32.1% in anterior and 60.0% in posterior septal ruptures. Univariate analysis identified emergency operation, New York Heart Association (NYHA) class, inotropic support, right ventricular dysfunction, intra-operative red blood cell transfusion, post-operative renal failure and renal replacement therapy (RRT) as predictors of operative mortality. Logistic multivariate analysis identified NYHA class and post-operative RRT as independent predictors of operative mortality. Five year survival was 44.4%. Right ventricular dysfunction, left ventricular ejection fraction (LVEF) and NYHA class were independent factors affecting long-term survival. Concomitant CABG during VSR repair did not significantly affect survival.

CONCLUSIONS: Surgical repair of post-infarction VSR carries a high operative mortality. NYHA class at presentation and post-operative RRT are predictors of early mortality. Right ventricular dysfunction, LVEF and NYHA class are independent factors influencing long-term survival. Concomitant CABG during VSR repair did not significantly improve survival.

CLINICAL IMPLICATIONS: These factors identified may aid in prognostication of patients undergoing surgical repair of VSR. The benefit of concomitant CABG during VSR repair remains uncertain.

DISCLOSURE: The following authors have nothing to disclose: Philip Yi Kit Pang, Yoong Kong Sin, Chong Hee Lim, Yeong Phang Lim, Jang Wen Su, Yeow Leng Chua

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National Heart Centre, Singapore, Singapore, Singapore

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    Print ISSN: 0012-3692
    Online ISSN: 1931-3543