Bilateral Indwelling Pleural Catheter Placement for Advanced Non-small Cell Lung Cancer with Recurrent Pleural Effusion
Kathleen M. Twomey, MD; Yu Maw Htwe, MD
Penn State Health Milton S. Hershey Medical Center
Pleural effusions are frequently observed in a variety of conditions. Reasons for intervention include obtaining an underlying diagnosis as to the cause and providing symptom relief. One of the most frequent causes of a recurrent pleural effusion is malignancy, which will typically continue to accumulate for as long as the cancer is progressing. When patients have a rapidly recurring effusion, requiring frequent intervention by way of thoracentesis or chest tube, other options for management are considered. An indwelling pleural catheter (IPC) can be offered to a patient to help drain the effusion on a regular basis, without requiring repeat thoracentesis. The goal of the drain placement is to provide symptom relief, and it is often in place for as long as the patient has an appreciable effusion that can be drained intermittently by vacuum canisters.
Open Left Upper Lobectomy in an Adult Cystic Fibrosis Patient
Douglas O’Connell, MSc1; Christopher R. Morse, MD2
1Touro University College of Osteopathic Medicine
2Massachusetts General Hospital
Cystic Fibrosis (CF) is an autosomal recessive genetic disorder characterized by mutations in the cystic fibrosis transmembrane regulator gene. The pathophysiology is based on abnormal chloride secretion from columnar epithelial cells. As a result, patients with CF have symptoms related to their inability to hydrate secretions in the respiratory tract, pancreas, and intestine, among other organs. In the lung, thick, inspissated secretions give rise to chronic obstructive pulmonary disease characterized by severe pulmonary infections, culminating in respiratory failure. Subacute exacerbations of CF lung disease are treated with antibiotics and various forms of chest physiotherapy. When large areas of the lung develop abscesses or necrosis, surgical treatment is often indicated. Options include lobectomy as a temporizing measure and lung transplantation for end-stage CF lung disease.
This article presents an unusual case of a man with CF whose lung function had remained relatively good until adulthood. His left upper lobe became chronically infected and progressively non-functional. Because the patient’s overall lung function was moderately preserved, an open left upper lobectomy was performed to prevent recurrences of subacute infections and subsequent damage to the left lung.
Chest Tube Placement for Possible Hemothorax
David V. Deshpande; Abigail Clarkson-During, MD; Jennifer Cone, MD; Ashley Suah, MD
UChicago Medicine
A hemothorax is a collection of blood within the pleural cavity. Blood can accumulate within this space as a sequelae of chest trauma (penetrating or blunt), iatrogenic injury (e.g., vascular access injuries), or spontaneously (e.g., due to malignancy). To treat the condition, a chest tube is inserted into the thoracic cavity on the affected side of the body. In addition to evacuating blood from the pleural cavity, a chest tube can also be used to treat pneumothorax (air in the pleural space) and pleural effusion (e.g., empyema or chylothorax), and to insert medications into the pleural space. Depending on the specific pathology, a tube or catheter may be utilized.
Robotic Thymectomy for Myasthenia Gravis
Constantine M. Poulos, MD1; Tong-Yan Chen, MD2; Lana Schumacher, MD, MS, FACS1
1Tufts Medical Center
2Massachusetts General Hospital
Myasthenia gravis is an autoimmune disease affecting acetylcholine transmission involved in skeletal muscle contraction. The approach to myasthenic patients is complex as optimal treatment involves a multidisciplinary technique of combined medical and surgical therapies. Medical therapy with acetylcholinesterases and immunomodulators can provide symptom relief and eliminate feelings of fatigue and weakness.
Surgical thymectomy can help by reducing symptoms, preventing recurrence, and reducing daily medication requirements. Thymectomy was traditionally performed via a transsternal approach, but minimally invasive and robotic techniques have become increasingly common. This article presents a robotic total thymectomy through a left-sided approach.
Insertion of a Right-Sided PleurX Catheter for Palliation of a Malignant Pleural Effusion
Andrew S. Chung, MD, PhD; Hugh G. Auchincloss, MD, MPH
Massachusetts General Hospital
The following case describes a 91-year-old woman with no significant past medical history who presented to her primary care physician with several months of cough and progressive dyspnea. After appropriate workup she was found to have a stage IVa lung adenocarcinoma with an associated malignant pleural effusion that contributed to her symptoms. There are several therapeutic options for treating a malignant pleural effusion. An indwelling tunneled pleural catheter (PleurX catheter) is a reliable way to manage a chronic pleural effusion. The device is most commonly used to manage malignant pleural effusions, but the same technique may be applied for a range of benign, non-infectious indications as well.
PleurX catheters may be inserted in an outpatient clinic, interventional radiology suite, inpatient setting, or operating room under local or general anesthesia. Once in place, they are designed to be managed in an outpatient setting either by the patient’s caregivers or by the patient themselves and serve to palliate the respiratory symptoms of a large effusion without the need for repeated thoracenteses. They can remain in place for several months, and removal in an outpatient setting with local anesthetic is trivial. Following placement of the PleurX catheter, the patient reported symptomatic improvement in her dyspnea, and she was started on dose-reduced Mobocertinib under the guidance of thoracic oncology.
Combined Thymectomy and Right Lower Lobe Pulmonary Wedge Resection by Thoracoscopy
M. Lucia Madariaga, MD; Henning A. Gaissert, MD
Massachusetts General Hospital
With the increasing use of computed tomography (CT) for screening and diagnostic workup, increasing numbers of patients are found to have pulmonary nodules. The patient in this case presented with vision changes, neck weakness, and dysphagia. Workup revealed non-thymomatous myasthenia gravis as well as an incidental right lower lobe lung nodule that was suspicious for malignancy based on imaging characteristics, interval growth, and history of breast cancer.
She required a lung resection for diagnostic and therapeutic purposes. Additionally, a thymectomy was indicated to help control her myasthenia gravis symptoms. Consequently, a combined approach was conducted.
Flexible Bronchoscopy and Bronchoalveolar Lavage (BAL)
Marcus S. Alpert, MD; Yu Maw Htwe, MD
Penn State Health Milton S. Hershey Medical Center
Flexible bronchoscopy is a commonly utilized endoscopic procedure allowing for direct visualization of the airways, as well as a variety of therapeutic and diagnostic interventions. Common indications of flexible bronchoscopy include evaluation of pulmonary infiltrates, hemoptysis, airway obstruction, foreign body aspiration, tracheal stenosis, bronchopleural fistula, and post-lung transplant.
The procedure involves the insertion of a flexible bronchoscope through the vocal cords and into the lumen of the trachea and bronchi. Direct visualization is provided by fiberoptic video imaging. Bronchoalveolar lavage (BAL) further refers to instillation and subsequent recovery of sterile saline into the airways. In this article, we will detail the technique, considerations, and complications of flexible bronchoscopy and BAL.
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