RATIONALE:Fungal empyema is a chronic refractory disease. It is difficult to control thoracic infection, and it is faced with the problem of recurrence. How to control the infection and reduce the probability of recurrence is a difficult problem. Surgical operation combined with endobronchial therapy was used to control infection, seal the fistula and eliminate residual cavity and achieved good results.PATIENT CONCERNS:A total of 5 patients with fungal empyema were treated from 2019 to 2021, aged 27 to 72 years, with an average age of 54.8 ± 7.6 years. Two cases were on the left side and 3 cases on the right side.DIAGNOSIS:While meeting the diagnostic criteria of empyema, the diagnosis of fungus in pus culture or the discovery of fungus in deep tissue pathology confirmed the diagnosis of fungal empyema in the 5 cases.INTERVENTIONS:Through surgical operations combined with bronchoscopy and individualized treatment, the infection was controlled, the fistulas were blocked, and the pus cavity was filled.OUTCOMES:After 11 to 30 months of follow-up, the muscle flap in the abscess cavity was mildly atrophied, and there was no recurrence of empyema. Three patients who completed the second-stage operation had their chest tubes removed and returned to normal life. The 2 patients who did not complete the second-stage operation had no recurrence of thoracic infection and no recurrence of cough or fever, and their quality of life was greatly improved.LESSONS:Surgical operation combined with bronchoscopy is a reliable method for the treatment of fungal empyema, which can find and plug the fistula more efficiently and eliminate the residual cavity by surgery to avoid recurrence. Therefore, it is a recommended treatment method.

RATIONALE:Pulmonary sequestration, which can be divided into 2 main types: intralobar pulmonary sequestration (IPS) and extralobar pulmonary sequestration, is an uncommon congenital condition for which surgical resection is usually indicated. Video-assisted thoracoscopic surgery, as compared with open thoracotomy, has increasingly become the preferred operative procedure in the treatment of PS, owing to less postoperative pain and faster recovery. This report describes a rare and challenging case with a giant IPS undergoing video-assisted thoracic lobectomy.PATIENT CONCERNS:A 39-year old woman suffered from recurrent pneumonia for nearly 3 years. An enhanced computed tomography scan performed in our hospital revealed a 12.0 cm × 10.0 cm-sized IPS in the left lower lobe, supplied by an 8-mm aberrant artery originating from the descending thoracic aorta.DIAGNOSIS:Histology of the resected lobe confirmed the diagnosis of giant intralobar pulmonary sequestration associated with infection.INTERVENTIONS:Thoracoscopic left lower lobectomy was performed.OUTCOMES:The patient has been discharged from the hospital on the ninth day after surgery with an uneventful recovery, she was in good health after a 1-year follow-up.LESSONS:Although full of challenges, thoracoscopic lobectomy for giant IPS is a safe and feasible surgical procedure associated with reduced surgical trauma and postoperative pain as well as improved cosmetic results compared with traditional thoracotomy.

Objective:To evaluate the safety and clinical efficacy of transplanting a muscle flap to treat the postoperative refractory empyema with a bronchopleural fistula.Methods:From July 2015 to December 2019, the clinical data of 15 patients who suffered from postoperative refractory empyema with bronchopleural fistula was retrospectively summarized. There were 13 males and two females with a mean age of 61.7 years. Ten cases had previous posterolateral thoracotomy and four cases underwent minimally invasive surgery. After conservative and endoscopic therapy, a pedicled latissimus dorsi muscle flap, a pectoralis major muscle flap, or a free vastus lateralis myocutaneous flap was harvested from the ipsilateral local thorax or thigh and was transferred to cover the intrathoracic cavity.Results:There was no perioperative death. During a mean follow-up of 14.8 months, one patient was dead, one suffered from a recurrence of refractory empyema, and l3 patients had an uneventful course with no recurrence of refractory empyema and bronchopleural fistula. Postoperative chest computed tomography or magnetic resonance imaging showed the empyema cavity was satisfactorily covered with a pedicle or free muscle flap.Conclusions:Muscle flap transplantation is an effective alternative for treating the postoperative refractory empyema with bronchopleural fistula, which can achieve promising short-medium-term results.

BACKGROUND:Empyema is a severe complication following pneumonectomy that is associated with high morbidity and mortality rates. Although there are a wide variety of treatment options, successful management remains challenging when this condition is combined with a large cavity in very thin patients who had previously undergone a posterolateral thoracotomy.CASE SUMMARY:We reported the case of a thin, 63-year-old man with a progressive pulmonary cyst who underwent left pneumonectomy via posterolateral thoracotomy 23 years ago. After an initially uneventful postoperative course, he was readmitted with empyema and a large cavity 21 years after surgery. He was successfully treated with limited thoracoplasty, followed by free vastus lateralis musculocutaneous flap transposition.CONCLUSION:This case highlights that the treatment mode of limited thoracoplasty and free vastus lateralis musculocutaneous flap transposition is safe and effective for the management of postpneumonectomy empyema with a large cavity in thin patients who had previously undergone a posterolateral thoracotomy.

目的 比较术前运用Hook-wire和医用胶两种定位方式行胸腔镜手术(VATS)切除孤立性肺小结节(SPN)的临床疗效.方法 选取2016年3月至2019年9月在浙江省立同德医院心胸外科同一医疗组行VATS的SPN患者共70例.所有患者均为单个结节定位,其中采用CT引导下Hook-wire定位者42例,医用胶定位者28例,观察和比较两组患者定位时间、定位成功率,气胸、出血、刺激性咳嗽等定位相关并发症发生率,同时记录比较两组患者VATS时间,统计两组术中冷冻切片病理检查结果.结果 所有患者均顺利完成术前CT引导下肺结节穿刺定位.两组患者定位时间比较差异无统计学意义(P>0.05);Hook-wire组定位成功率明显低于医用胶组,差异有统计学意义(P<0.05).Hook-wire组气胸和渗血的发生率均明显高于医用胶组,差异均有统计学意义(均P<0.05);医用胶定位组咳嗽的发生率明显高于Hook-wire组,差异有统计学意义(P<0.05).所有患者均顺利完成VATS,Hook-wire组VATS时间明显长于医用胶组,差异有统计学意义(P<0.05);而两组患者术中冷冻切片病理检查结果比较差异无统计学意义(P>0.05).结论 CT引导下Hook-wire或医用胶定位均可用于VATS切除SPN,安全性高,可简化VATS操作难度,缩短时间,医用胶相比Hook-wire定位成功率高、手术用时更短,相关并发症少,予以优先推荐.

BACKGROUND:Pericardial rupture caused by blunt chest trauma is rare in clinical practice. Because of its atypical clinical symptoms, and because surgeons are often unfamiliar with the clinical and radiological manifestations of the injury, preoperative diagnosis is difficult; it is easily misdiagnosed and causes serious consequences.CASE SUMMARY:A 60-year-old man, previously healthy, was transported to the emergency room after falling from a great height. Upon arrival, his vital signs were stable. Electrocardiography and echocardiography were performed, and there was no sign of cardiac injury or ischemia. Chest and abdomen computerized tomography revealed pneumopericardium, hemopneumothorax, lung contusion, multiple rib fractures on the right side (Figure 1), and right scapula and clavicle fractures. He was admitted to the inpatient department for further observation after tube thoracostomy. The next day, the patient suddenly experienced rapid arrhythmia (the ventricular rate reached 150-180 beats/min) when turning onto his right side, accompanied by a blood pressure drop to 70/45 mm Hg and a chief complaint of palpitation. Thoracoscopy was performed urgently, and a large vertical tear (8 cm × 6 cm) was found in the pericardium. The defect was successfully repaired using a heart Dacron patch. His postoperative condition was uneventful without any fluctuations in vital signs, and he was transferred to the orthopedics department for further surgery on postoperative day 8.CONCLUSION:Although the possibility of pericardial rupture combined with cardiac hernia is extremely low, it is one of the causes of cardiogenic shock following blunt trauma. Therefore, clinicians need to be more familiar with its characteristic manifestations and maintain a high degree of vigilance against such injuries to avoid disastrous consequences.

BACKGROUND:Bronchopleural fistula (BPF) refers to an abnormal channel between the pleural space and the bronchial tree. It is a potentially fatal postoperative complication after pulmonary resection and a complex challenge for thoracic surgeons because many patients with BPF ultimately develop refractory empyema, which is difficult to manage and has a major impact on quality of life and survival. Therefore, an operative intervention combined with conservative and endoscopic therapies may be required to control infection completely, to occlude BPF, and to obliterate the empyema cavity during treatment periods.CASE PRESENTATION:Two patients who suffered from BPF complicated with chronic empyema after lobectomy were treated in other hospitals for a long time and did not recover. In our department, we performed staged surgery and creatively combined an Amplatzer Septal Occluder (ASO) device (AGA Medical Corp, Golden Valley, MN, USA) with pedicled muscle flap transposition. First, open-window thoracostomy (OWT), or effective drainage, was performed according to the degree of contamination in the empyema cavity after the local infection was controlled. Second, Amplatzer device implantation and pedicled muscle flap transposition was performed at the same time, which achieved the purpose of obliterating the infection, closing the fistula, and tamponading the residual cavity. The patients recovered without complications and were discharged with short hospitalization stays.CONCLUSIONS:We believe that the union of the Amplatzer device and pedicle muscle flap transposition seems to be a safe and effective treatment for BPF with chronic empyema and can shorten the length of the related hospital stay.

自发性食管破裂是一种罕见疾病,而在肠道准备过程中发生自发性食管破裂更是罕见.该病的死亡率很高,治疗原则是清除污染源,封闭裂口,恢复食管完整性,充分引流,控制感染,加强营养支持,改善身体状况,促进伤口愈合.但关键是避免患者在肠道准备过程中因剧烈呕吐而发生自发性食管破裂,笔者建议小口、多次服用导泻剂.

目的 总结1例闭合性颈段气管断裂伤的诊治经验,进一步提高对该病的认识和诊疗水平.方法 患者,男性,41岁.颈部被钢板撞击伤后出现高度皮下气肿、呼吸困难,皮下排气后症状改善不明显,紧急行颈胸部CT检查发现高度皮下和纵隔气肿、颈部气管不连续,考虑气管断裂伤,在急诊手术中发现气管1～2环间全断离,伴软骨骨折、周围软组织损伤,行气管断端吻合、低位气管切开术.结果 术后恢复顺利,2周后拔除气管套管,病人呼吸、进食正常,但出现声音嘶哑,喉镜检查发现声带固定,半年后复查胸部CT气管断端吻合口无狭窄,因声音嘶哑未改善行双侧声带切除和气管切开术,带气管套管至今2年余.结论 闭合性颈段气管断裂伤可能引起气道梗阻而窒息死亡,救治成功的关键是确保气道通畅、早期做出正确诊断和及时重建断裂气管,气管吻合术能取得满意的疗效.

目的 总结和分析支气管胸膜瘘合并难治性脓胸个体化综合治疗的方法和疗效.方法2015年7月—2019年11月共收治支气管胸膜瘘合并难治性脓胸患者12例,其中男性10例,女性2例;年龄23～78岁,平均(60.75±15.05)岁.初始手术为非小细胞肺癌4例,肺部良性疾病4例,包裹性胸腔积液3例,恶性胸腺瘤肺转移1例.胸膜瘘发生后,采取经脓胸引流控制感染和介入封堵瘘口治疗;病情基本稳定后,行肌瓣移植术填塞脓腔等综合措施,并根据病情进行个体化治疗.结果全组无围手术期死亡病例;在平均17.45个月的随访中,1例患者因肿瘤转移死亡;1例复发小脓腔;其余10例无支气管胸膜瘘和脓胸复发,肌瓣存活,复查胸部CT/MRI显示脓腔被彻底填塞.结论对支气管胸膜瘘合并难治性脓胸患者采取个体化综合治疗措施,能达到彻底根治的目的,成功率高,疗效显著,值得推广.

2015年5月至2019年9月应用游离股外侧肌皮瓣移植术治疗7例顽固性慢性脓胸，其中男5例，女2例；年龄23～70岁，平均(66.38±11.24)岁。脓胸均为胸部外科手术后并发症，右侧6例，左侧1例。术中取游离股外侧肌皮瓣填塞脓腔，显微镜下行旋股外侧动脉降支动脉、静脉与胸背动、静脉间断缝合，以提供该组织瓣的血供。术后游离肌皮瓣成活6例，失活1例。术后随访(26.5±18.2)个月，1例恶性胸腺瘤转移复发，术后半年死亡；其他6例均肌瓣成活，脓腔填塞良好，无脓胸复发，无胸闷等不适。肌瓣供区愈合良好，下肢功能无明显影响。游离股外侧肌皮瓣移植术能有效填塞脓胸残腔，不改变胸廓外形，不影响下肢功能，适用于含有巨大脓腔、无法使用带蒂和其他游离肌皮瓣的术后慢性脓胸，近、中期疗效满意，是一种可供选择的理想方法，值得临床推广。

慢性脓胸通过开窗引流、胸膜剥脱术、胸廓成形术、介入封堵等治疗可以取得比较理想的效果,但临床上仍有一些患者因存在不易被彻底清除的巨大脓腔,也可能合并胸膜支气管瘘、胸壁窦道、残留骨和软骨等坏死组织,从而导致局部感染不易控制而难以彻底根治.笔者应用联合带蒂肌瓣移植术治疗慢性难治性脓胸15例.现报道如下.

目的 观察血管内皮生长因子(VEGF)对大鼠离体心脏骨髓间充质干细胞(BMSCs)滞留率的影响.方法 取20只雄性SD大鼠,腹腔注射麻醉无菌条件下取股骨和胫骨,用DMEM培养基缓慢冲洗骨髓腔,离心收集细胞,接种到DMEM培养基原代培养,取传代3代后的BMSCs.另取100只雌性SD大鼠随机分成正常灌注BMSCs组、正常灌注BMSCs+VEGF组、缺血再灌注BMSCs组、缺血再灌注BMSCs+VEGF组,每组25只.正常灌注BMSCs组大鼠建立心脏离体灌注模型,灌注1 ×106/mL BMSCs细胞1mL,停2min后重新灌注,于5、10、30、60、120min时间点收集从心脏流出的灌注液,每个时间点5只.正常灌注BMSCs+VEGF组大鼠灌注BMSCs前预先向心脏注入浓度1000μmol/L的VEGF 1mL,其他实验步骤与正常灌注BMSCs组相同.缺血再灌注BMSCs组大鼠建立心脏离体灌注模型,待心脏稳定搏动15min后,关闭灌注系统使心肌缺血30min,建立缺血再灌注模型,其他实验步骤与正常灌注BMSCs组相同.应用荧光定量聚合酶链反应(RT-PCR)检测各组大鼠高体心脏不同时间点骨髓间充质干细胞滞留率.结果 正常灌注BMSCs组大鼠5、15、30、60、120min时间点之间平均BMSCs滞留率差异无统计学意义(P＞0.05);缺血再灌注BMSCs组大鼠5、15、30、60、120min时间点平均BMSCs滞留率均高于正常灌注BMSCs组[(36.96±4.79)％比(16.32±3.84)％、(35.88±4.76)％比(14.02±5.23)％、(28.05±3.46)％比(12.48±3.46)％、(27.04±6.35)％比(12.42±3.61)％、(27.06±5.84)％比(12.42±3.49)％,P均＜0.05];与正常灌注BMSCs+VEGF组比较,缺血再灌注BMSCs+VEGF组平均BMSCs滞留率明显增加[(41.46±5.88)％比(19.38±4.66)％、(37.82±5.74)比(19.54±5.11)％、(32.82±3.53)比(16.68±2.64)％、(33.24±6.19)比(16.06±2.12)％、(31.60±3.24)比(15.60±2.00)％,P均＜0.05);正常灌注BMSCs+VEGF组与正常灌注BMSCs组同时间点平均BMSCs滞留率比较,差异无统计学意义(P＞0.05);缺血再灌注BMSCs+VEGF组与缺血再灌注BM-SCs组同时间点平均BMSCs滞留率比较,差异无统计学意义(P＞0.05).结论 缺血再灌注可显著增加大鼠离体心脏骨髓间充质干细胞滞留率;而血管内皮生长因子对其无明显干预作用.

目的 探讨胸腔镜探查联合小切口辅助对多发肋骨骨折内固定治疗的临床疗效.方法 回顾分析2015年8月至2018年2月间我科收治的严重胸部钝性伤行手术内固定病人共32例,所有患者均于伤后一周内在胸腔镜下探查,并辅助予8 cm左右的小切口,选用镍钛记忆合金肋骨环抱器固定肋骨,重塑胸壁的结构及稳定性,同时记录与手术相关数据指标.结果 32例患者均顺利完成胸腔探查+肋骨内固定手术,平均肋骨固定数5.6根(4～11根),平均手术时间为126 min(86～180 min),术中平均出血量:130 mL(100～250 mL),术后平均拔管时间3 d(2～5 d),术后平均住院时间:8.5 d(6～15 d),术后平均随访6月,2例患者出现胸壁慢性疼痛,无死亡及其他严重并发症患者.结论 胸腔镜辅助小切口治疗严重多发肋骨骨折安全、有效,它能使内固定手术更加微创化,促进患者快速康复.

肺淋巴管平滑肌瘤病(PLAM)是一种罕见的、以肺部广泛囊性病变为特征的进行性全身疾病,可与结节性硬化症(TSC)合并发生[1].本病常见于育龄期妇女,女性散在发病率约为1/40万,首发症状无特异性,部分医师对其缺乏认识,故常出现漏诊和误诊情况.浙江省立同德医院2017年收治1例PLAM患者,其诊断、治疗及时,相关影像、病理资料完整,现报道如下.

Endotracheal/endobronchial metastasis (EEM) generally originates from nonpulmonary malignancies such as cancers of the breast, colon, and kidney. Although the incidence of EEM has been reported to be between 2.0% and 50.0%, cases diagnosed after radical resection of primary lung cancer are extremely rare.[12] We hereby presented a patient of squamous cell lung carcinoma who was confirmed to have EEM 3 years after his radical resection of primary tumor. A 46-year-old male smoker was admitted on July 20, 2011, because of repeated nonproductive cough and blood-tinged sputum for approximately one month. The chest computed tomography (CT) scan showed a right hilar nodule of <2.0 cm in diameter which partially occluded the right upper lobe bronchus with local atelectasis [Figure 1a]. Mass at the orifice of the right upper bronchus was detected by bronchoscopy while no other lesion was observed in the mucosa of tracheal and bronchial. Pathologic analysis of the specimen suggested a malignant suspected neoplasm. A right upper sleeve lobectomy and systemic lymph node dissection was performed and a mass of 1.8 cm × 1.0 cm × 0.8 cm was excised. The tumor was further proved by histopathology to be a primary moderate differentiate squamous cell lung carcinoma which positively expressed markers of P63, P40, and cytokeratin (CK) 5/6. Four out of 32 peribronchial lymph nodes were positive for metastasis analysis whereas the bronchial margins were negative which confined the stage to be pT1aN1M0 (Stage IIa). Thus, chemotherapy was applied. During the 36-month postoperative follow-up, the patient was asymptomatic with negative chest CT screening [Figure 1b]. However, the last bronchoscopy examination conducted 3 years after his radical resection of primary lung cancer revealed multiple tiny nodules of approximately 0.1 cm in diameter in the left main bronchus. These lesions were further characterized to be squamous cell carcinoma which had identical pathologic features as the primary resected tumor [Figure 1c and 1d]. Therefore, the patient received sequential treatment of transbronchial argon knife therapy, endotracheal radiotherapy, and chemotherapy for conservative treatments until no lesion of tiny nodules could be detected by bronchoscopy [Figure 1e]. The patient was still alive after 14-month follow-up.Figure 1: Endobronchial metastases after radical resection of a primary lung cancer. (a) Preoperative chest computed tomography scan showed a right hilar nodule of <2.0 cm in diameter (arrow); (b) Postoperative 36-month chest computed tomography scan was negative (arrow); (c) Bronchoscopy presented multiple very tiny nodules located in the left main bronchus (arrow); (d) Histology showed moderately differentiated squamous cell carcinoma (arrow) expressing P63, P40 within the nucleus and cytokeratin 5/6 in the cytoplasm by immunohistochemistry, identical to previously resected primary lung cancer (Hematoxylin-eosin, original magnification ×100); (e) Transbronchial argon knife therapy was performed (arrow).EEM is defined as bronchoscopically visible pulmonary tumors located in the subsegmental or more proximal central bronchi which have identical histopathology characteristics comparing to the primary tumor. To the best of our knowledge, very few cases of EEM which happed after the radical resection of primary lung cancer have been reported.[134] Metachronous recurrence usually develops at least several months after the resection of the primary site, while synchronous recurrence develops with the primary tumor.[12] The interval time of metachronous recurrence has been reported to be 8–52 months (mean, 25.8 months) and the incidence is about 0.4%.[3] The symptoms associated with EEM are similar to those with primary endotracheal/endobronchial tumor regardless of its primary site. It has been reported that hemoptysis with coughing is the most common symptom, with an incidence of 41.0–62.0%, while dyspnea and wheezing occurring are less often. Still, about 26.0–62.5% of the patients can be totally asymptomatic.[3] Postoperative follow-up, chest CT scan might detect the main lesions of EEM which can be presented as nodules or wall thickness of trachea and bronchus. The bronchoscopy is a valuable tool for detection of EEM as the CT scan may give false negative results, which is just the case of the patient presented in this report.[34] The main aim of performing bronchoscopy was to exclude postoperative recurrence of local bronchial anastomosis because he underwent a right upper sleeve lobectomy with central lung cancer in the right upper lobe and chemotherapy was applied due to pathology Stage IIa 3 years ago. The diagnosis is usually rely on the histology and immunohistochemistry and sometimes also by gene mutation analysis of epidermal growth factor receptor (EGFR), Kirsten Ras (KRAS), and anaplastic lymphoma kinase (ALK).[1] The histology usually revealed all tracheal tumor cells were involved the submucosal layer and some were found within the submucosal lymphatic vessels presenting as tumor emboli, so cause of EEM was thought that tracheal tumor cells might originate from the primary site through submucosal lymphatic or blood vessels rather than from carcinoma in situ.[3] The setup of treatment should take several factors into consideration, including the histopathological feature and biological behavior of the primary tumor, the anatomic location of the primary as well as the metastatic lesions, and the general status of the patients. The final clinical management strategy can be highly individualized.[34] Surgical excision, local radiotherapy, and transbronchial endoscopic procedures might all be part of the therapy. The effective palliative treatments are brachytherapy, photodynamic therapy, and laser ablation. The patient underwent transbronchial argon knife therapy (ERBE Elektromedizin GmbH, Tuebingen, Germany) and endotracheal radiotherapy and the reasonable result was achieved. Although EEM is generally a manifestation of a far-advanced disease stage which indicates poor prognosis, the outcome of the patients might still depend largely on the biological behavior of the particular tumor and its responsiveness to the treatments.[3] In summary, we presented a case of endobronchial metastases after radical resection of a primary squamous cell lung carcinoma. The experience suggests that bronchoscopy is of great value in detecting insidious EEM lesions and palliative treatment could be performed after the diagnosis of EEM. Financial support and sponsorship This study was supported by a grant from Zhejiang Province Traditional Chinese Medicine Scientific Research Fund (No. 2011ZB012). Conflicts of interest There are no conflicts of interest.

笔者应用手术治疗气管憩室1例，报道如下。