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Recovery of Lung Perfusion After Sleeve Resection for Tuberculous Bronchial Stenosis
Recovery of Lung Perfusion After Sleeve Resection for Tuberculous Bronchial Stenosis Shoji Takahashi, MD, Yoshinobu Hata, MD, PhD, Shuichi Sasamoto, MD, PhD, Fumitomo Sato, MD, Kazuyoshi Tamaki, MD, Keita Sato, MD, Aki Mitsuda, MD, PhD, Kazutoshi Shibuya, MD, PhD, and Keigo Takagi, MD, PhD Department of Chest Surgery, Pulmonary Medicine and Surgical Pathology, Toho University Omori Medical Center, Tokyo, Japan
Parenchyma-sparing main bronchial sleeve resection is a safe and effective procedure to restore impaired lung function. We present a case illustrating recovery of lung perfusion in a 24-year-old woman with dyspnea on exertion because of bronchial tuberculosis. Bronchoscopic examination revealed pin-hole stenosis of the left main bronchial orifice. 99mTc-macroaggregated albumin perfusion scanning revealed essentially absent left lung perfusion. Because of bronchomalacia in the distal portion, six rings of the left main bronchus were resected by carinoplasty. Symptoms abated and perfusion recovered to a large extent 2 months later. She became pregnant and delivered successfully 12 months postoperatively. (Ann Thorac Surg 2012;93:2041–3) © 2012 by The Society of Thoracic Surgeons
P
arenchyma-sparing main bronchial sleeve resection is reported to be a safe and effective procedure in selected patients, in whom it can preserve and restore impaired lung function [1– 4]. One concern is whether the chronically atelectatic lung can resume meaningful functionality after airway reconstruction, but cases of both airway patency and lung function restoration after atelectasis lasting as long as 9 years have been reported [5]. Moreover, one study reported persistent shunt with reestablished ventilation 11 years after traumatic rupture of the left main bronchus, probably because of localized thickening of the alveolocapillary membrane or blood flow to unventilated areas [6]. Although restoration of anatomic continuity does not guarantee recovery of normal function, recovery of both perfusion and ventilation is clearly a prerequisite for recovery of gas exchange. We present a case of a young woman with dyspnea on exertion caused by tuberculous bronchial stenosis who underwent left main sleeve resection resulting in improved perfusion. She then went on to a successful pregnancy and delivered a healthy baby. A 24-year-old woman presented with productive cough, stridor, and dyspnea on exertion after antituberculous therapy. A chest radiograph showed a hyperlucent left
Accepted for publication Oct 7, 2011. Address correspondence to Dr Hata, Department of Chest Surgery, Toho University Omori Medical Center, 6-11-1 Omori-nishi, Ota-ku, Tokyo 143-8541, Japan; e-mail: [email protected].
© 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc
lung field and decreased left vascular shadow (Fig 1). Chest computed tomography (CT) revealed severe stenosis of the left main bronchus at its origin and middle portion. The distal portion of the left main bronchus and the segmental orifices of the upper and lower lobes had a normal appearance. Bronchoscopic examination revealed pin-hole stenosis of the left main bronchus at its origin. Pulmonary function testing indicated a restrictive impairment. Forced vital capacity was 2 L (72% of the predicted normal value). Forced expiratory volume in 1 second was 1.66 L (56% of normal). Perfusion lung scanning with 99mTc-macroaggregated albumin revealed decreased perfusion fraction of the left lung to only 8%. Ventilation lung scanning with 133Xe gas indicated decreased ventilation at 35% in the early phase, with delayed washout of 63% in the late phase, implying central airway stenosis. Because the patient was young and wished to conceive, a left main bronchial sleeve resection with one-stomatype carinoplasty was selected as the favored approach to restoring pulmonary function. After partial excision of the left side of the carina and distal trachea, we planned to resect four rings of the left main bronchus using a mediastinal approach. Because of unanticipated bronchomalacia of the distal portion of the left main bronchus, an additional two-ring resection was required. Thereafter, airway anastomosis reconstruction with a pedicled pericardial fat pad wrapping was performed successfully. The resected specimen revealed fibrostenosis in the first four rings and bronchomalacia with destroyed cartilage in the last two rings. The postoperative course was uneventful, and respiratory symptoms were abrogated. Two months postoperatively, chest CT and bronchoscopic examination showed a patent anastomosis without stenosis (Fig 2). Pulmonary function tests showed improvement to within the normal range. The forced vital capacity improved to 2.63 L (88% of predicted normal) and the forced expiratory volume in 1 second improved to 2.31 L (78% of normal). Perfusion lung scanning with 99m Tc-macroaggregated albumin revealed that the perfusion fraction of the left lung was partially recovered, at 25%. Ventilation lung scanning with 133Xe gas indicated improved ventilation of the left lung, at 45% in the early phase, and only a slight wash-out delay, which was 48% in the late phase. The patient became pregnant and delivered successfully 12 months postoperatively.
Comment Spitzer and colleagues [7] reported 2 patients with intraluminal carcinoid tumors resulting in unilateral hyperlucency and no perfusion of the lung. Resection of the tumors and reconstruction of bronchial continuity resulted in a gradual return of perfusion to normal between 3 and 18 months later. Thus, there was a long delay before perfusion returned to normal, and this was dependent on the degree of vasoconstriction before surgery [1]. Bagan and colleagues [1] reported that 2 patients with 0003-4975/$36.00 doi:10.1016/j.athoracsur.2011.10.027
FEATURE ARTICLES
CASE REPORTS
2042
CASE REPORT TAKAHASHI ET AL LUNG PERFUSION AFTER SLEEVE RESECTION
Ann Thorac Surg 2012;93:2041–3
Fig 1. (A) Chest radiograph showing hyperlucent left lung. (B) Chest computed tomography showing stenotic lesions in the left main bronchus. (C) Bronchofiberscopic findings of pin-hole stenosis of left main bronchus orifice.
FEATURE ARTICLES
incomplete arterial vasoconstriction recovered normal function by 3 months, whereas 9 patients with completely absent pulmonary perfusion recovered over a mean period of 8 months. In their series [1], main bronchial sleeve resection restored perfusion of the impaired lung from 0% to 20%–35% despite a period of preoperative atelectasis of up to 60 months. In this case, preoperative lung perfusion of the impaired side was severely reduced to 8%, and parenchymal-preservation left main sleeve resection restored this to 25% 2 months postoperatively. Although radiologic follow-up was discontinued because of pregnancy, we infer that perfusion completely recovered thereafter. Although the possibility cannot be excluded that recovery of perfusion does not necessarily imply recovery of gas exchange to the same extent, symptoms of dyspnea on exertion abated, and the baby was delivered uneventfully. Thus, main bronchial resection can be an effective procedure for select patients, even after several months or years of atelectasis, allowing the pulmonary parenchyma to be preserved and function to be restored. Evaluating airway integrity beyond the point of severe stenosis is sometimes problematic. Although CT imaging can visualize distal airways that are not accessible to bronchoscopy, we failed to detect the bronchomalacia Fig 2. Two months postoperatively. (A) Chest computed tomography showing a patent anastomosis. (B) Bronchofiberscopic findings at the anastomosis site.
secondary to tuberculous inflammation and destruction of cartilage, which otherwise would have been included in the plan for resection of the fibrostenotic portion. We therefore recommend that possible malacia beyond the fibrostenotic area in bronchial tuberculosis always need to be suspected. Recently reported dynamic expiratory CT for detecting bronchomalacia [8] might be a useful tool in this respect. A total of six rings of the left main bronchus—including the two extra, unanticipated rings of the malacia—were successfully resected in the present case. It has been reported that the entire left main bronchus can be removed successfully [2– 4], but sleeve resection with left upper or lower lobectomy has been suggested as a less radical alternative to reduce the anastomotic tension caused by the expanded lung trapped in the aortopulmonary window [2]. A left pneumonectomy should be the last alternative that needs to be considered.
References 1. Bagan P, Le Pimpec-Barthes F, Badia A, Crockett F, Dujon A, Riquet M. Bronchial sleeve resections: lung function resurrecting procedure. Eur J Cardiothorac Surg 2008;34:484 –7.
Ann Thorac Surg 2012;93:2043– 4
Conservative Management of a Bilothorax Resulting From Blunt Hepatic Trauma Avraham Z. Cooper, BA, Alok Gupta, MD, and Stephen R. Odom, MD, FACS Harvard Medical School and Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
Pleurobiliary fistula after blunt abdominal trauma is rare. We report a case managed with tube thoracostomy alone, without the need for biliary system drainage. (Ann Thorac Surg 2012;93:2043– 4) © 2012 by The Society of Thoracic Surgeons
T
he treatment of traumatic hepatic injuries and their sequelae remains a challenge. Conservative, nonoperative management has become the standard of care for patients in hemodynamically stable condition after blunt trauma, with a success rate of greater than 90% [1]. Given this trend, certain clinical problems that were once rare in the era of operative intervention may become more prevalent. Thus, a greater understanding of the causes and management of these eventualities is warranted. One such example is the development of a pleurobiliary fistula and subsequent bilothorax [1]. We report a case of blunt hepatic trauma and resultant pleurobiliary fistula and bilothorax, which were managed conservatively. A 21-year-old woman, otherwise healthy, was trampled by a horse. She was found to have a grade V liver laceration (Fig 1) and T8 –T10 rib fractures. She was transiently hypotensive but responded to intravenous
Accepted for publication Nov 7, 2011. Address correspondence to Dr Odom, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St, Ste 2-G, Boston, MA 02215; e-mail: [email protected].
© 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc
2043
Fig 1. Computed tomography scan demonstrating severe liver laceration with perihepatic hematoma.
fluid administration. Her hematocrit was 30% upon admission and remained stable. There was no evidence of active bleeding, so she was observed, eventually her diet was advanced, and she began oral pain medications. She was discharged home from the trauma unit on posttrauma day 8 with a hematocrit of 29% without blood transfusion. On post-injury day 18, she described having pleuritic pain in the inferior right part of the thorax. On examination, her oxygen saturation was 100% and her respiratory rate was 30. Her breath sounds were diminished and there were crackles in the right lung base. A chest roentgenogram and computed tomography showed a right pleural effusion (Fig 2A). A right thoracostomy tube was inserted, which drained 2100 mL of bilious fluid. Analysis demonstrated a bilirubin level of 4.9 (compared with 0.8 in serum). Drainage output was 20 mL over the next 48 hours. The thoracostomy tube was removed, and the patient was discharged home. On post-injury day 36, her chest roentgenogram (Figure 2b) and the results of examination were normal, with no evidence of recurrent bilothorax.
Comment Bilothorax after blunt hepatic trauma is rare. Most cases of pleurobiliary fistula have been reported after hepatic abscess formation or biliary tract obstruction [2]. Some rare cases of pleurobiliary fistula result from abdominal trauma [3]. Because bilothorax is rare, experience with it is limited. In addition, the management is quite complex and involves serious concomitant injuries that must be prioritized and managed sequentially. The presumed mechanism of bilothorax formation is from pleurobiliary formation, with a presumptive diaphragmatic disruption. Penetrating wounds causing such a fistula would require thoracic and abdominal drainage with repair of the diaphragmatic injury. Subsequent fistula would develop only in cases where liver lacerations have been inadequately drained or the diaphragmatic injury has been missed [2]. At that point, operative 0003-4975/$36.00 doi:10.1016/j.athoracsur.2011.11.024
FEATURE ARTICLES
2. Maeda M, Nakamoto K, Tsubota N, Okada T, Katsura H. Operative approaches for left-sided carinoplasty. Ann Thorac Surg 1993;56:441–5. 3. Newton JR Jr, Grillo HC, Mathisen DJ. Main bronchial sleeve resection with pulmonary conservation. Ann Thorac Surg 1991;52:1272– 80. 4. Cerfolio RJ, Deschamps C, Allen MS, Trastek VF, Pairolero PC. Mainstem bronchial sleeve resection with pulmonary preservation. Ann Thorac Surg 1996;61:1458 – 62. 5. Nonoyama A, Masuda A, Kasahara K, Mogi T, Kagawa T. Total rupture of the left main bronchus successfully repaired nine years after injury. Ann Thorac Surg 1976;21:445– 8. 6. Mahaffey DE, Creech O Jr, Boren HG, Debakey ME. Traumatic rupture of the left-main bronchus successfully repaired eleven years after injury. J Thorac Surg 1956;32:312–31. 7. Spitzer SA, Segal I, Lubin E, Nili M, Levy M. Unilateral increased transradiancy of the lung caused by bronchial carcinoid tumour. Thorax 1980;35:739 – 44. 8. Lee KS, Sun MR, Ernst A, Feller-Kopman D, Majid A, Boiselle PM. Comparison of dynamic expiratory CT with bronchoscopy for diagnosing airway malacia: a pilot evaluation. Chest 2007;131:758 – 64.
CASE REPORT COOPER ET AL TRAUMATIC BILOTHORAX
Parenchyma-sparing main bronchial sleeve resection is a safe and effective procedure to restore impaired lung function. We present a case illustrating recovery of lung perfusion in a 24-year-old woman with dyspnea on exertion because of bronchial tuberculosis. Bronchoscopic examination revealed pin-hole stenosis of the left main bronchial orifice. 99mTc-macroaggregated albumin perfusion scanning revealed essentially absent left lung perfusion. Because of bronchomalacia in the distal portion, six rings of the left main bronchus were resected by carinoplasty. Symptoms abated and perfusion recovered to a large extent 2 months later. She became pregnant and delivered successfully 12 months postoperatively. (Ann Thorac Surg 2012;93:2041–3) © 2012 by The Society of Thoracic Surgeons
P
arenchyma-sparing main bronchial sleeve resection is reported to be a safe and effective procedure in selected patients, in whom it can preserve and restore impaired lung function [1– 4]. One concern is whether the chronically atelectatic lung can resume meaningful functionality after airway reconstruction, but cases of both airway patency and lung function restoration after atelectasis lasting as long as 9 years have been reported [5]. Moreover, one study reported persistent shunt with reestablished ventilation 11 years after traumatic rupture of the left main bronchus, probably because of localized thickening of the alveolocapillary membrane or blood flow to unventilated areas [6]. Although restoration of anatomic continuity does not guarantee recovery of normal function, recovery of both perfusion and ventilation is clearly a prerequisite for recovery of gas exchange. We present a case of a young woman with dyspnea on exertion caused by tuberculous bronchial stenosis who underwent left main sleeve resection resulting in improved perfusion. She then went on to a successful pregnancy and delivered a healthy baby. A 24-year-old woman presented with productive cough, stridor, and dyspnea on exertion after antituberculous therapy. A chest radiograph showed a hyperlucent left
Accepted for publication Oct 7, 2011. Address correspondence to Dr Hata, Department of Chest Surgery, Toho University Omori Medical Center, 6-11-1 Omori-nishi, Ota-ku, Tokyo 143-8541, Japan; e-mail: [email protected].
© 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc
lung field and decreased left vascular shadow (Fig 1). Chest computed tomography (CT) revealed severe stenosis of the left main bronchus at its origin and middle portion. The distal portion of the left main bronchus and the segmental orifices of the upper and lower lobes had a normal appearance. Bronchoscopic examination revealed pin-hole stenosis of the left main bronchus at its origin. Pulmonary function testing indicated a restrictive impairment. Forced vital capacity was 2 L (72% of the predicted normal value). Forced expiratory volume in 1 second was 1.66 L (56% of normal). Perfusion lung scanning with 99mTc-macroaggregated albumin revealed decreased perfusion fraction of the left lung to only 8%. Ventilation lung scanning with 133Xe gas indicated decreased ventilation at 35% in the early phase, with delayed washout of 63% in the late phase, implying central airway stenosis. Because the patient was young and wished to conceive, a left main bronchial sleeve resection with one-stomatype carinoplasty was selected as the favored approach to restoring pulmonary function. After partial excision of the left side of the carina and distal trachea, we planned to resect four rings of the left main bronchus using a mediastinal approach. Because of unanticipated bronchomalacia of the distal portion of the left main bronchus, an additional two-ring resection was required. Thereafter, airway anastomosis reconstruction with a pedicled pericardial fat pad wrapping was performed successfully. The resected specimen revealed fibrostenosis in the first four rings and bronchomalacia with destroyed cartilage in the last two rings. The postoperative course was uneventful, and respiratory symptoms were abrogated. Two months postoperatively, chest CT and bronchoscopic examination showed a patent anastomosis without stenosis (Fig 2). Pulmonary function tests showed improvement to within the normal range. The forced vital capacity improved to 2.63 L (88% of predicted normal) and the forced expiratory volume in 1 second improved to 2.31 L (78% of normal). Perfusion lung scanning with 99m Tc-macroaggregated albumin revealed that the perfusion fraction of the left lung was partially recovered, at 25%. Ventilation lung scanning with 133Xe gas indicated improved ventilation of the left lung, at 45% in the early phase, and only a slight wash-out delay, which was 48% in the late phase. The patient became pregnant and delivered successfully 12 months postoperatively.
Comment Spitzer and colleagues [7] reported 2 patients with intraluminal carcinoid tumors resulting in unilateral hyperlucency and no perfusion of the lung. Resection of the tumors and reconstruction of bronchial continuity resulted in a gradual return of perfusion to normal between 3 and 18 months later. Thus, there was a long delay before perfusion returned to normal, and this was dependent on the degree of vasoconstriction before surgery [1]. Bagan and colleagues [1] reported that 2 patients with 0003-4975/$36.00 doi:10.1016/j.athoracsur.2011.10.027
FEATURE ARTICLES
CASE REPORTS
2042
CASE REPORT TAKAHASHI ET AL LUNG PERFUSION AFTER SLEEVE RESECTION
Ann Thorac Surg 2012;93:2041–3
Fig 1. (A) Chest radiograph showing hyperlucent left lung. (B) Chest computed tomography showing stenotic lesions in the left main bronchus. (C) Bronchofiberscopic findings of pin-hole stenosis of left main bronchus orifice.
FEATURE ARTICLES
incomplete arterial vasoconstriction recovered normal function by 3 months, whereas 9 patients with completely absent pulmonary perfusion recovered over a mean period of 8 months. In their series [1], main bronchial sleeve resection restored perfusion of the impaired lung from 0% to 20%–35% despite a period of preoperative atelectasis of up to 60 months. In this case, preoperative lung perfusion of the impaired side was severely reduced to 8%, and parenchymal-preservation left main sleeve resection restored this to 25% 2 months postoperatively. Although radiologic follow-up was discontinued because of pregnancy, we infer that perfusion completely recovered thereafter. Although the possibility cannot be excluded that recovery of perfusion does not necessarily imply recovery of gas exchange to the same extent, symptoms of dyspnea on exertion abated, and the baby was delivered uneventfully. Thus, main bronchial resection can be an effective procedure for select patients, even after several months or years of atelectasis, allowing the pulmonary parenchyma to be preserved and function to be restored. Evaluating airway integrity beyond the point of severe stenosis is sometimes problematic. Although CT imaging can visualize distal airways that are not accessible to bronchoscopy, we failed to detect the bronchomalacia Fig 2. Two months postoperatively. (A) Chest computed tomography showing a patent anastomosis. (B) Bronchofiberscopic findings at the anastomosis site.
secondary to tuberculous inflammation and destruction of cartilage, which otherwise would have been included in the plan for resection of the fibrostenotic portion. We therefore recommend that possible malacia beyond the fibrostenotic area in bronchial tuberculosis always need to be suspected. Recently reported dynamic expiratory CT for detecting bronchomalacia [8] might be a useful tool in this respect. A total of six rings of the left main bronchus—including the two extra, unanticipated rings of the malacia—were successfully resected in the present case. It has been reported that the entire left main bronchus can be removed successfully [2– 4], but sleeve resection with left upper or lower lobectomy has been suggested as a less radical alternative to reduce the anastomotic tension caused by the expanded lung trapped in the aortopulmonary window [2]. A left pneumonectomy should be the last alternative that needs to be considered.
References 1. Bagan P, Le Pimpec-Barthes F, Badia A, Crockett F, Dujon A, Riquet M. Bronchial sleeve resections: lung function resurrecting procedure. Eur J Cardiothorac Surg 2008;34:484 –7.
Ann Thorac Surg 2012;93:2043– 4
Conservative Management of a Bilothorax Resulting From Blunt Hepatic Trauma Avraham Z. Cooper, BA, Alok Gupta, MD, and Stephen R. Odom, MD, FACS Harvard Medical School and Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
Pleurobiliary fistula after blunt abdominal trauma is rare. We report a case managed with tube thoracostomy alone, without the need for biliary system drainage. (Ann Thorac Surg 2012;93:2043– 4) © 2012 by The Society of Thoracic Surgeons
T
he treatment of traumatic hepatic injuries and their sequelae remains a challenge. Conservative, nonoperative management has become the standard of care for patients in hemodynamically stable condition after blunt trauma, with a success rate of greater than 90% [1]. Given this trend, certain clinical problems that were once rare in the era of operative intervention may become more prevalent. Thus, a greater understanding of the causes and management of these eventualities is warranted. One such example is the development of a pleurobiliary fistula and subsequent bilothorax [1]. We report a case of blunt hepatic trauma and resultant pleurobiliary fistula and bilothorax, which were managed conservatively. A 21-year-old woman, otherwise healthy, was trampled by a horse. She was found to have a grade V liver laceration (Fig 1) and T8 –T10 rib fractures. She was transiently hypotensive but responded to intravenous
Accepted for publication Nov 7, 2011. Address correspondence to Dr Odom, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St, Ste 2-G, Boston, MA 02215; e-mail: [email protected].
© 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc
2043
Fig 1. Computed tomography scan demonstrating severe liver laceration with perihepatic hematoma.
fluid administration. Her hematocrit was 30% upon admission and remained stable. There was no evidence of active bleeding, so she was observed, eventually her diet was advanced, and she began oral pain medications. She was discharged home from the trauma unit on posttrauma day 8 with a hematocrit of 29% without blood transfusion. On post-injury day 18, she described having pleuritic pain in the inferior right part of the thorax. On examination, her oxygen saturation was 100% and her respiratory rate was 30. Her breath sounds were diminished and there were crackles in the right lung base. A chest roentgenogram and computed tomography showed a right pleural effusion (Fig 2A). A right thoracostomy tube was inserted, which drained 2100 mL of bilious fluid. Analysis demonstrated a bilirubin level of 4.9 (compared with 0.8 in serum). Drainage output was 20 mL over the next 48 hours. The thoracostomy tube was removed, and the patient was discharged home. On post-injury day 36, her chest roentgenogram (Figure 2b) and the results of examination were normal, with no evidence of recurrent bilothorax.
Comment Bilothorax after blunt hepatic trauma is rare. Most cases of pleurobiliary fistula have been reported after hepatic abscess formation or biliary tract obstruction [2]. Some rare cases of pleurobiliary fistula result from abdominal trauma [3]. Because bilothorax is rare, experience with it is limited. In addition, the management is quite complex and involves serious concomitant injuries that must be prioritized and managed sequentially. The presumed mechanism of bilothorax formation is from pleurobiliary formation, with a presumptive diaphragmatic disruption. Penetrating wounds causing such a fistula would require thoracic and abdominal drainage with repair of the diaphragmatic injury. Subsequent fistula would develop only in cases where liver lacerations have been inadequately drained or the diaphragmatic injury has been missed [2]. At that point, operative 0003-4975/$36.00 doi:10.1016/j.athoracsur.2011.11.024
FEATURE ARTICLES
2. Maeda M, Nakamoto K, Tsubota N, Okada T, Katsura H. Operative approaches for left-sided carinoplasty. Ann Thorac Surg 1993;56:441–5. 3. Newton JR Jr, Grillo HC, Mathisen DJ. Main bronchial sleeve resection with pulmonary conservation. Ann Thorac Surg 1991;52:1272– 80. 4. Cerfolio RJ, Deschamps C, Allen MS, Trastek VF, Pairolero PC. Mainstem bronchial sleeve resection with pulmonary preservation. Ann Thorac Surg 1996;61:1458 – 62. 5. Nonoyama A, Masuda A, Kasahara K, Mogi T, Kagawa T. Total rupture of the left main bronchus successfully repaired nine years after injury. Ann Thorac Surg 1976;21:445– 8. 6. Mahaffey DE, Creech O Jr, Boren HG, Debakey ME. Traumatic rupture of the left-main bronchus successfully repaired eleven years after injury. J Thorac Surg 1956;32:312–31. 7. Spitzer SA, Segal I, Lubin E, Nili M, Levy M. Unilateral increased transradiancy of the lung caused by bronchial carcinoid tumour. Thorax 1980;35:739 – 44. 8. Lee KS, Sun MR, Ernst A, Feller-Kopman D, Majid A, Boiselle PM. Comparison of dynamic expiratory CT with bronchoscopy for diagnosing airway malacia: a pilot evaluation. Chest 2007;131:758 – 64.
CASE REPORT COOPER ET AL TRAUMATIC BILOTHORAX