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This study demonstrates the development of a sensitive, specific, and quantitative peptide-based nanoprobe prototype assay for the detection of Legionellaceae in a simple way and in a short time. In this work, proteases present in the culture supernatants of Legionella spp. were used as a biomarker. Fluorogenic peptide substrates, specific to Legionella strains culture supernatant proteases, were identified. Peptidases produced a significant increase in the fluorescence intensity following the cleavage of the dipeptide fluorogenic substrates. The specific substrates were identified and coupled with carboxyl-terminated nano-magnetic particles (NMPs). On the other hand, the C-terminal was conjugated with the cysteine residue to covalently integrate with a gold sensing platform via the Au-S linkage. Four different sensors were fabricated from the four specific substrates, which were treated with the protesase of six different species of Legionella. In the presence of specific protease, the peptide sequence is digested and the magnetic nanobeads moved out of the gold surface, resulting in the apparence of gold color. One of the nanoprobes sensitivity detects as low as 60 CFU mL-1 of Legionella anisa, Legionella micdadei, and Fluoribacter dumoffii. The cross-reactivity of the sensors was tested using other closely associated bacterial species and no significant cross-reactivity of the sensors was found. It is envisaged that this assay could be useful for screening purposes or might be supportive for the fast and easy detection of Legionella protease activity for water monitoring purposes.

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An 11-year-old girl presented with severe respiratory distress, fever and septic manifestations. Computed tomography scan (CT) of the chest showed 2 separate superior and posterior mediastinal cysts, the upper one causing severe extrinsic compression of the trachea, and the oesophagus, while the lower cyst was at the subcarinal region compressing the 2 major bronchi. Emergency thoracotomy was performed permitting complete resection of intra-mural oesophageal enteric cyst, and a subcarinal bronchogenic cyst. The postoperative course was uneventful.

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BACKGROUND: A retrospective study and analysis was performed to determine the value and benefit of pulmonary metastatectomy for soft tissue sarcomas, and which factors predict prognosis following resection. METHODS: Twenty-three patients underwent resections for pulmonary metastases from a soft tissue sarcoma (STS) at King Faisal Specialist Hospital and Research Center (KFSH&RC), between January 1985 and December 1998. There were 11 male and 12 female patients. Thirteen of 23 patients (57%) had one to three metastases, and 10 (43%) had four or more metastases. A total of 41 thoracic explorations was performed for the 23 evaluable patients. Median sternotomy was used only for three patients and lateral thoracotomy was used for 20 patients as an initial surgical approach. Pulmonary resections performed included one or more wedge resections (n=16), segmentectomy (n=5), and lobectomy (n=2). No one in this series underwent pneumonectomy. The number of resected metastatic nodules ranged from one-six with average three. Eight patients (35%) received various kinds of postoperative adjuvant chemotherapy. RESULTS: The overall and disease-free survival rate post-metastatectomy at five years was 24% and 21%, respectively. Various prognostic indicators were examined to evaluate their association with improved survival. Age, sex localization of the primary site and histologic type, tumor grade, size of the resected nodules, laterality (unilateral or bilateral), types of resection, adjuvant chemotherapy, and local recurrence did not significantly affect survival. However, patient with disease free interval >6 months, and those with three or fewer metastases showed a trend toward a higher five-year overall survival (p=0.06, 0.07, respectively). CONCLUSIONS: Surgical excision of lung metastases from soft tissue sarcomas is well accepted and should be considered as a first line of treatment if preoperative evaluation indicated that complete resection of the metastases is possible. Further investigation is needed before chemotherapy can be recommended as additional therapy.

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OBJECTIVE: To compare the outcome of surgical resection for aspergilloma between patients with post-tuberculous complex and neutropenia. METHODS: We retrospectively reviewed our surgical experience with pulmonary resection for aspergilloma in 30 patients. Of the 20 patients with complex aspergilloma complicating healed tuberculosis (group 1), 14 were male and six were female with an average age of 54 years (SD 7). The indication for surgery was recurrent haemoptysis in all and there were 17 lobectomies, two pneumonectomies and one bilateral lobectomy. There were ten patients with acute myeloid or lymphoid leukemia (group 2), six male and four female with an average age of 26 years (SD 4). Twelve lesions required lobectomy in eight and wedge excision in four. RESULTS: In group 1 there was one post-operative death (5%), in a patient with massive haemoptysis and completely destroyed lungs with bilateral upper lobe aspergilloma secondary to pneumonia. Morbidity accounted for 25% (five patients), two required re-exploration for bleeding, two had prolonged air leak more than 7 days and one developed empyema. The later was treated with drainage and rib resection. One patient had recurrence of haemoptysis during the follow up period (mean 42 months). In group 2 there was no mortality or morbidity and six patients proceeded to bone marrow transplantation with no complication or recurrence. CONCLUSIONS: Surgical resection for pulmonary aspergilloma in selected patients provides the best chance of cure. Pulmonary resection for post-tuberculous complex aspergilloma is associated with higher morbidity than resection for immuno-compromised patients.

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OBJECTIVE: In an attempt to establish a treatment protocol for tuberculous empyema, we retrospectively reviewed our experience over a 3-year period. METHODS: Between January 1996 and December 1998, 26 patients (23 male and three female) with an average age of 33.8 years (range 18-61 years) presented with tuberculous empyema. The empyema was right-sided in 13, left-sided in 12 and bilateral in one patient. Patients presented with respiratory symptoms for a mean duration of 4.43 months (range 1-48 months). All patients had a computerized scan of the chest and managed according to the stage of empyema. RESULTS: In patients with exudative empyema (n=4) the fluid was aspirated, but one patient required intercostal tube (ICT) drainage for 6 days. There were four patients with fibrinopurulent empyema treated with thoracoscopic drainage with a mean post-operative stay of 8 days (range 4-12 days). In the organizing stage (n=18), initial drainage with large ICT was performed. The pleura was less than 2 cm in thickness in eight patients, for which repeated installation of streptokinase was performed (three to seven times). Satisfactory results were achieved in six patients (75%) and the remaining two required decortication. Of the ten patients with thick cortex, one required a window and nine had decortication, two of which had additional lobectomy and two had pneumonectomy. All patients fully recovered with no mortality and with a mean duration of drainage of 18 days (range 3-61 days). CONCLUSION: Its stage and the state of the underlying lung should guide surgical treatment for tuberculous empyema. This protocol aims to achieve cure utilizing the least invasive approach and acceptable hospital stay.

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A-19-year old male patient complained of shortness of breath. Aspiration of the pleural fluid revealed chylothorax. Right chest tube was inserted. His ABG showed hypoxaemia with relative hypercarbia. He underwent right thoracotomy and thoracic duct ligation under general anaesthesia and double lumen endobroncheal intubation. During surgery he lost 1.5 L of blood and 4 L chyle. He was transferred to the SICU intubated and on mechanical ventilation. On the subsequent days chyle leak was reduced to a minimum of 10 ml/hr. On the 9th postoperative day the patient was extubated. He was receiving TPN 2600 kcal/day. He was transferred to the normal floor on the 15th day. After 7 day he was readmitted, his chest showed severe lung fibrosis and consolidation. His ABG showed severe hypercarbia (PaCO2 = 126 mmHg). The patient was intubated. His condition deteriorated and he was considered for lung transplantation. No donor was available. Later he arrested and died. Anaesthesia and surgical management of spontaneous chylothorax is challenging. The mortality rate is high.

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BACKGROUND: Video-assisted thoracoscopic surgery (VATS) has become an established technique in both diagnostic and therapeutic thoracic surgery procedures. PATIENTS AND METHODS: In an attempt to evaluate the current indications and outcome of this technique, 143 VATS procedures, which were performed over a three-year period, were retrospectively evaluated. Indications included lung biopsy in 46, recurrent or persistent pneumothorax in 42, and pleural disease in 16 patients. Other indications included sympathectomy in eight, mediastinal mass in three, pericardial window in three, metastasectomy in three, and staging of lung cancer in two patients. RESULTS: There was one postoperative death (0.7%), a patient with massive pleural effusion and end-stage renal and hepatic failure. Conversion to formal thoracotomy was necessary in six patients (4.2%), and was the result of adhesions in four, bleeding in one, and failure to identify the lesion in one patient. Diagnostic procedures were considered successful in 44 out of 46 lung biopsies (95.7%), 15 out of 16 pleural disease cases (93.8%), and two lung cancer staging cases. The other 79 therapeutic VATS procedures were all effective, both in the long and short term, apart from two cases of prolonged air leak after VATS for pneumothorax, one of which was considered a failure (2.4%). CONCLUSION: VATS should be available in each thoracic surgery unit. It is both safe and effective in a variety of diagnostic and therapeutic procedures.

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The ideal classification system for bronchiectasis continues to be debated. As an alternative to the present morphologic classification, a hemodynamic-based functional classification is proposed. This study examines the rationale for and outcome of surgery based on this classification in patients with unilateral or bilateral bronchiectasis. Between July 1987 and January 1997 the morphologic and hemodynamic features in 85 bronchiectatic patients were examined: 18 with bilateral bronchiectasis and 67 with unilateral disease. A policy of unilateral lung resection of the nonperfused bronchiectasis and preservation of the perfused type was adopted in all patients. The mean age at operation was 29.4 +/- 9.7 years (range 6-55 years) with a mean follow-up period of 45.2 +/- 21.0 months (range 2-120 months). Left-sided predominance of bronchiectasis was evident in this series both in frequency and severity. In those with unilateral disease, bronchiectasis was left-sided in 49 (73.1%) patients and right-sided in 18 (26.9%). The left lung was totally bronchiectatic in 11 (16.4%) patients and the right in 3 (4.4%). Moreover, among the patients with bilateral bronchiectasis, 14 of 18 (77.7%) patients had the left lung more severely involved. Based on the morphologic and hemodynamic features in the investigated patients, two types of bronchiectasis were recognized: a perfused type with intact pulmonary artery flow and a nonperfused type with absent pulmonary artery flow. Lobectomy was performed in 55 patients, basal segmentectomy and preservation of the apical segment in 16, and pneumonectomy in 14. There was no mortality in this series. Altogether 63 patients (74.1%) achieved excellent results, 19 (22.4%) scored good results, and 3 (3.5%) patients had not benefited from surgery at last follow-up. In the face of the general criticism of the traditional morphologic classification, the proposed classification not only predicts whether the involved lung will have a measure of respiratory function with regard to gas exchange but reflects the degree of severity of the disease process. Thus the question of which side to resect and which to preserve is defined more precisely. This classification was found to be logical, physiologically sound, and of proven benefit.

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OBJECTIVE: To assess the long term efficacy of intercostal tube drainage for spontaneous pneumothorax and determine the clinical parameters associated with surgery. EXPERIMENTAL DESIGN: Retrospective analysis with a mean follow-up of 62.3+/-19.3 months (range 23 to 94 months). SETTING: Riyadh Medical Complex, Riyadh (Saudi Arabia), the biggest referral centres for Ministry of Health providing specialized hospital care. PATIENTS: Over a period of six year, 123 patients had 182 episodes of spontaneous pneumothorax. Male to female ratio was 29.75:1 (p=0.00001). Average age was 26.35+/-8.33 years for men and 37.25+/-14.6 years for women (p=0.01). Seventy eight per cent of patients were aged 11 to 30 years (p=0.00001). Majority were nonsmokers (100/123, p=0.00001). It was first episode of spontaneous pneumothorax for 86 patients. Other 37 patients had 57 episodes previously (mean 1.54+/-0.73; range 1 to 4). INTERVENTIONS: Intercostal tube drainage for all patient with spontaneous pneumothorax. Limited axillary thoracotomy with bullectomy and pleuroabrasion for 32 patients not responding to intercostal tube drainage. RESULTS: Intercostal tube drainage alone had success rate of 90.7% in first, 52.4% in second, 15.4% in third and 0% for more than 3 episodes of spontaneous pneumothorax. Among the 32 patients who underwent surgery, only one had early recurrence that did not require drainage. We found that patients with history of recurrence, respiratory distress and those requiring tube thoracostomy for more than 4 days and negative suction to expand the lung were more liable to undergo surgical intervention (p=0.00001 for all variables). CONCLUSIONS: We recommend early surgery to hasten recovery and shorten the hospital stay in patients with history of recurrent spontaneous pneumothorax, respiratory distress and those requiring tube thoracostomy for more than 4 days and negative suction to expand the lung.

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BACKGROUND: Despite improving results in lung transplantation, a significant number of grafts fail early or late postoperatively. The pulmonary retransplant registry was founded in 1991 to determine the predictors of outcome after retransplantation. We hypothesized that ambulatory status of the recipient and center retransplant volume, which had been previously shown to predict survival after retransplantation, would also be associated with improved graft function postoperatively. METHODS: Two hundred thirty patients underwent retransplantation in 47 centers from 1985 to 1996. Logistic regression methods were used to determine variables associated with, and predictive of, survival and lung function after retransplantation. RESULTS: Kaplan-Meier survival was 47% +/- 3%, 40% +/- 3%, and 33% +/- 4% at 1, 2, and 3 years, respectively. On multivariable analysis, the predictors of survival included ambulatory status or lack of ventilator support preoperatively (p = 0.005; odds ratio, 1.62; 95% confidence interval, 1.15 to 2.27), followed by retransplantation after 1991 (p = 0.048; odds ratio, 1.41; 95% confidence interval, 1.003 to 1.99). Ambulatory, nonventilated patients undergoing retransplantation after 1991 had a 1-year survival of 64% +/- 5% versus 33% +/- 4% for nonambulatory, ventilated recipients. Eighty-one percent, 70%, 62%, and 56% of survivors were free of bronchiolitis obliterans syndrome at 1, 2, 3, and 4 years after retransplantation, respectively. Factors associated with freedom from stage 3 (severe) bronchiolitis obliterans syndrome at 2 years after retransplantation included an interval between transplants greater than 2 years (p = 0.01), the lack of ventilatory support before retransplantation (p = 0.03), increasing retransplant experience within each center (fifth and higher retransplant patient, p = 0.04), and total center volume of five or more retransplant operations (p = 0.05). CONCLUSIONS: Nonambulatory, ventilated patients should not be considered for retransplantation with the same priority as other candidates. The best intermediate-term functional results occurred in more experienced centers, in nonventilated patients, and in patients undergoing retransplantation more than 2 years after their first transplant. In view of the scarcity of lung donors, patient selection for retransplantation should remain strict and should be guided by the outcome data reviewed in this article.

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OBJECTIVE: To asses the incidence of local recurrence and distant metastases after complete resection for stage I lung cancer in order to predict the predominant prognostic factors. METHODS: We retrospectively reviewed 123 patients with stage I lung cancer who underwent curative resection over a 2-year period between January 1987 and December 1988. There were 83 male and 40 female patients with a mean age of 64.8 +/- 12 years (range between 39 and 82 years). Multivariate analysis of prognostic factors for long term survival was undertaken. RESULTS: T1N0 lesions were found in 34 patients and T2N0 in 89. The histological diagnosis was Squamous carcinoma in 75, Adenocarcinoma in 38, large cell carcinoma in 6 and small cell carcinoma in 4 patients. Pneumonectomy was performed in 27 patients (5 T1 and 22 T2) while 96 required lobectomy (29 T1 and 67 T2). At 5 years 50 patients died. This was due to local recurrence in 12, distant metastasis in 24, second primary in 1, unrelated disease in 3, while the cause was unknown in 10 patients. At 5 years, 10 patients were alive with evidence of recurrence. The mean interval for local recurrence was 19.8 months and for distant metastasis was 18 months. The overall 5 year survival was 67% +/- 4 for T1 and 56% +/- 5 for T2 lesions (NS). The rate of recurrence was significantly less for T1 lesions (P = 0.02). Survival was significantly less for patients requiring pneumonectomy rather than lobectomy (P = 0.01) whether for T1 or T2. CONCLUSION: In stage I lung cancer T2 lesions requiring pneumonectomy for complete resection had a worse prognosis and higher incidence of local recurrence.

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OBJECTIVE: To describe a technique of direct revascularisation of the bronchial artery using the left IMA and assess its medium term results in patients undergoing left single lung transplant (SLT). METHODS: Between March 1991 and September 1993, 22 patients who underwent direct bronchial revascularisation at the time of left SLT (20 pedicled IMA, one free IMA, and one direct anastomosis to the aorta) have been followed up for a minimum period of 1 year (mean 30 +/- 12 months). Their mean age was 47.8 +/- 9.6 and the original disease was emphysema in 19, lymphangioleiomyomatosis in two, and pulmonary fibrosis in one. The mean ischaemia time was 269.7 +/- 23.4 min. RESULTS: There was one early death (4.5%) and 3 patients were re-explored for bleeding. The actuarial survival at 1 and 3 years was 91 +/- 0.4% and 82.6 +/- 1%, respectively. Bronchial healing was excellent in all patients and angiographic studies showed patent vascular anastomosis in all 22 patients, with good run off in 20 and poor in two. One patient developed clinical obliterative bronchiolitis at 22 months (4.5%) during a period of follow up varying from 12 to 43 months (mean 30 S.D. 12). At last follow up the mean FEV1 was 1.4 +/- 0.4 and the mean FVC was 2.2 +/- 0.6. On average, each patient developed 1.5 +/- 0.6 infection episodes and 1 +/- 0.2 acute lung rejection. CONCLUSION: It is concluded that the medium term results of direct bronchial revascularisation are good. However the influence of this procedure on long term results needs further investigation.

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The present paper describes eight patients (two teenagers and six adults) who had chronic symptoms (haemoptysis, cough, recurrent pneumonia) caused by foreign body (FB) inhalation which went undetected for 3 months to 25 yr. None of the patients had the usual predisposing conditions like mental retardation, seizures or brain tumour. The diagnosis of FB was made by radiography in one patient only. Computerized tomography visualized one FB (a beef bone), and bronchoscopy identified FB in another two patients. The remaining four cases were diagnosed at thoracotomy. Removal of FB was curative in three of five cases who required surgical resection for irreversible bronchiectatic changes. The severity of pulmonary changes correlated with duration of symptoms. It is concluded that chronic, unexplained respiratory symptoms should warrant further investigation to exclude FB despite negative history and normal chest radiography. Finding of granulation tissue or cicatricial stenosis of the bronchus could be the only clue to the presence of a FB. Early diagnosis would avoid irreversible parenchymal changes which necessitate lung resection.

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OBJECTIVE: Single lung transplantation (SLT) for emphysema has given satisfactory long term results in most patients. The mediastinal shift caused by the native emphysematous lung may require further surgical intervention in selected cases. METHODS: We report a technique of simultaneous SLT and volume reduction of the contralateral lung in 4 patients with end stage respiratory failure secondary to emphysema. There were two right and two left SLT, performed in two male and two female patients. Their mean age was 52.2 (S.D. 4) years (range between 41 and 57 years) and the ischaemia time averaged 255.6 (S.D. 16) min (range between 225 and 255 min). The volume of the contralateral lung was reduced using staples. The stapled lines were buttressed by the donors pericardium. RESULTS: Their were no operative related complications apart from air leak which settled spontaneously within 5 days postoperatively. Teh pre-operative FEVI showed a mean value of 0.57 (S.D. 0.1) L (17.2% (S.D. 2) of the predicted) which improved to 1.79 (S.D. 0.4) L (58.2% (S.D. 8) of the predicted) at last follow up (P < 0.005). Radiological examinations at 1 year showed central mediastinum with satisfactory respiratory function. CONCLUSION: We conclude that this technique can be performed for patients with emphysema without increase in the operative morbidity and with good early respiratory function. Further follow up is required to assess the long term results of this procedure.

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STUDY OBJECTIVE: Severe idiopathic scoliosis is associated with respiratory failure. This usually is secondary to restrictive airway disease and reduced vital capacity. Patients may also suffer from an increase in airway resistance when severe kyphoscoliosis is present. SETTING: Three patients (two of whom required assisted ventilation) with varying degrees of kyphoscoliosis presented with moderate to severe breathing difficulties. INTERVENTION: Bronchoscopic examination of these patients showed evidence of torsion with secondary obstruction of the central airways. RESULTS: The airway obstruction was notable for its slit-like appearance, for the normality of the mucosa at the site of the obstruction, for the relative ease through which an instrument could traverse the obstruction, and once the retained secretions had been cleared, for the preservation of normal anatomy of the distal airways. The insertion of metal prostheses to stent the areas of obstruction prompted an impressive improvement in respiratory status, radiologic findings, and spirometric criteria in each case. Improvement has been maintained over a maximum follow-up period of 4 years. CONCLUSION: Severe kyphoscoliosis can lead to bronchial torsion and obstruction of the central airways. Patients should be assessed by bronchoscopy to exclude this deformity or any other cause of obstruction. The use of a metal endobronchial stent has been effective in both the immediate and long-term period.

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