Thoracoscopy for Empyema and Hemothorax Rodney J. Landreneau, Robert J. Keenan, Stephen R. Hazelrigg, Michael J. Mack and Keith S. Naunheim Chest 1996;109;18-24 DOI 10.1378/chest.109.1.18 The online version of this article, along with updated information and services can be found online on the World Wide Web at: http://chestjournal.org/cgi/content/abstract/109/1/18 CHEST is the official journal of the American College of Chest Physicians. It has been published monthly since 1935. Copyright 2007 by the American College of Chest Physicians, 3300 Dundee Road, Northbrook IL 60062. All rights reserved. No part of this article or PDF may be reproduced or distributed without the prior written permission of the copyright holder (http://www.chestjournal.org/misc/reprints.shtml). ISSN: 0012-3692. Downloaded from chestjournal.org on March 30, 2008 Copyright © 1996 by American College of Chest Physicians for Empyema and Thoracoscopy Hemothorax* Robert J. Keenan, MD; Rodney J.R.Landreneau, MD;Michael J. Mack, MD; and StephenS. Hazelrigg,MDMD; Keith Naunheim, Video-assisted thoracic surgery (VATS) has assumed greater importance in the management of pleural disease. Since 1990, we have performed VATS proce¬ dures to manage a variety of pathologic pleural pro¬ cesses in 306 patients. The 99 patients with complex empyemas or hemothoraces are the focus of this report. Seventy-six patients with complex empyemas (including 26 chronic) were approached with VATS after inadequate chest tube drainage. The causes associated with the thoracic empyemas were parap¬ neumonic collections in 47, after hemothorax in 8, in¬ fected sympathetic effusions associated with intra-abdominal sepsis in 6, postresectional in 5, prolonged fistula following spontaneous pneubronchopleural mothorax in 4, chronic drainage of malignant pleural effusions in 4, and chronic drainage of pleural effusion in 2 patients undergoing chemotherapy. Ages ranged from 14 to 78 years. Sixty-three patients (83%) were treated with thoracoscopic drainage ±decortication alone. Thirteen patients (17%) required subsequent thoracotomy for decortication, including 12 of the 26 (46%) chronic empyemas known to be greater than 3 weeks old. Chest tubes were removed 3.3 ±2.9 days tal stay for these patients with empyema averaged 7.4 ±7.2 days. There were five deaths, all related to progressive sepsis from associated pneumonia (6.6%). Twenty-three patients underwent thoracoscopic evac¬ uation of hemothoraces that resulted following open heart surgery in 6, thoracic trauma in 7, were iatrogenic in 7, and bleeding into malignant effusions in 3. All were successfully treated by thoracoscopic drain¬ age and pleural debridement alone. Chest tubes were removed 2.8 ±0.5 days postoperatively and hospital stay averaged 4.3 ±1.9 days. There were no complica¬ tions; one patient with a hemothrax (after heart trans¬ plant) died of unrelated causes. In our experience, VATS has been highly successful in the early manage¬ ment of empyemas and hemothoraces. Conversion to open thoracotomy must always be anticipated, espe¬ cially when approaching chronic empyemas. (CHEST 1995; 109:18-24) VATS=video-assisted thoracic surgery postoperatively in 67 patients; 9 patients (12%) were sent home with empyema tubes. Postoperative hospi¬ Key words: empyema; hemothorax; thoracoscopy/pleuros- T oculated empyemas and hemothoraces recalcitrant -¦--1 to tube thoracostomy drainage continue to be difficult management problems. The frequent associ¬ ation of other significant medical illnesses among pa- prolongation of the patient's illness and the ultimate need for more extensive surgical interventions.1"12 Although thoracoscopy's utility in the evaluation and treatment of pleural disease processes has been rec¬ ognized for many years,13,14 relatively little has been described about the role of thoracoscopy, or videoassisted thoracic surgery (VATS), as an alternative to thoracotomy for definitive management of empyema or hemothorax.15"24 The recent development of wide- For editorial comment see page 2 tients with empyema and the presence of coexisting multisystem injuries in trauma victims with hemotho¬ rax often lead us away from considering early definitive open surgical management of these processes. Thoracentesis or repeated tube thoracostomy drainage are often chosen as the primary treatments of these prob¬ lems. Delays in accurately diagnosing and effectively managing these pleural problems, however, can result *From the Section of Thoracic Surgery, University of Pittsburgh (Drs. Landreneau and Keenan); and the Divisions of Cardiotho¬ racic Surgery, University of Southern Illinois Medical School, Carbondale (Dr. Hazelrigg); St. Louis (Mo) University (Dr. Naunheim); and Medical City Hospital-Dallas (Dr. Mack). Presented at the 1993 Western Surgical Society Annual Meeting, Seattle. Manuscript received March 6, 1995; revision accepted May 2. 18 copy; video-assisted thoracic surgery (VATS) in angled video-optical endoscopic equipment and more effective endosurgical instrumentation has expanded the role of this minimally invasive surgical approach to a wide variety of thoracic surgical problems previously requiring thoracotomy for their management.2526 This report focuses on our recent experience with the VATS approach as primary management of complex he¬ mothoraces and thoracic empyema. Materials and Methods Patient Profile From December 1990 to November 1994, we have used videoassisted thoracic surgical approaches to manage pleural pathologic Downloaded from chestjournal.org on March 30, 2008 Copyright © 1996 by American College of Chest Physicians Clinical Investigations Table Table 2.Etiology of Empyema (n=76) 1.Thoracoscopic Management of Pleural Effusions (n-306) Etiology No. Management Posttraumatic 118 Diagnosis of idiopathic effusions 15 Idiopathic Parapneumonic (systemic disease) Malignant Treatment of known malignant effusions Transudate Treatment of empyema Treatment of hemothorax 8 24 71 89 76 23 (hemothorax) patients (Table 1). Sixty-seven percent of these patients (n=207) underwent VATS for the diagnosis of idiopathic of known malignant pleural processes or for the management tube thoracostomy pleural effusions that had failed to respond tounderwent VATS to The 99 alone. remaining patients drainage approach complex empyemas and hemothoraces recalcitrant to simple tube thoracostomy management. when standard chest The empyemas were considered "complex" chest CT identified significant multiloculated radiographs and/or fluid collections with associated pulmonary parenchymal compres¬ sion or consolidation (Fig 1). The clinical etiologies of the empye¬ mas are detailed in Table 2. The bacteriologic profile of the pleu¬ ral infections was quite broad with staphylococcal species being the most common pathogens (41%). Mixed aerobic/anaerobic infec¬ tions were seen in 26% of patients and a variety of infectious agents were cultured in 18% of cases. No growth on pleural fluid culture occurred in 15% of patients. The patients ranged in age from 14 to 78 years (mean, 47 years). The median duration of the pleural pro¬ cess for these patients prior to the VATS management was 9 days; however, 26 patients had chronic pleural space infections persist¬ ing for greater than 3 weeks. All of these empyema patients treated with VATS had previously been approached with systemic antibi¬ otic therapy and primary tube thoracostomy drainage of the pleu¬ ral collection. The duration of tube thoracostomy drainage ranged from 1 to 11 days prior to consultation for the VATS intervention. A significant minority of patients (n=21,28%) had numerous (range, 8 Parapneumonic 47 Postresectional 5 Chronic drainage of malignant effusion Spontaneous pneumothorax 4 4 Infected sympathetic effusion-abdominal sepsis Postchemotherapy 2 Table processes in 306 No. 6 3.Etiology of Hemothoraces (n=23) Etiology No. Posttraumatic After open heart surgery Iatrogenic Malignant 2 to 4) attempts at tube thoracostomy drainage before the referral for "surgical" intervention. The causes associated with the hemothoraces managed in this experience are listed in Table 3. All of these patients with hemothorax had a previous attempt at tube thoracostomy drainage of the intrathoracic clot prior to the VATS consultation (Fig 2). The decision to perform the thoracoscopic management was based on the need to evacuate significant retained hemothoraces to avoid or empyema. In this pulmonaryto restriction delayed complicationsnoof occasion use the VATS approach for the experience, there was short-term evaluation or treatment of ongoing chest tube bleeding or to urgently explore the thoracic cavity for occult intrathoracic or diaphragmatic injury. Preoperative Preparation and VATS Technique Careful study of the preoperative radiographic studies is impor¬ tant before initiating the thoracoscopic intervention so that the best location for intercostal access can be determined. The patient is Figure 2. Posteroanterior chest radiograph of a large clotted he¬ Figure 1. CT tion. demonstrating loculated pustulant pleural collec¬ mothorax persisting after attempted tube thoracostomy drainage that was successfully managed with VATS debridement and evac¬ uation of the pleural cavity. Downloaded from chestjournal.org on March 30, 2008 CHEST /109 / 1 / JANUARY, 1996 Copyright © 1996 by American College of Chest Physicians 19 thick adhesions thin adhesions loculated pus pockets grasper through biopsy channel of thora scope Figure 3. Illustration of the pathologic processes resulting in loc¬ ulated pleural processes requiring VATS intervention. brought to the operating room where general anesthesia is used to conduct the procedure. After induction of anesthesia, a fi¬ through the enberoptic bronchoscopic examinationa is performed dotracheal tube on all patients with diagnosis of empyema to rule out the presence of an obstructing endobronchial lesion that would prevent full reexpansion of the lung. Bronchoscopic examination is also performed in all cases of idiopathic hemothorax. Conversion to a double-lumen endotracheal tube is then accomplished to achieve selective lung ventilation of the contralateral lung and collapse ofthe ipsilateral lung during the VATS intervention.20 Theispatient is then hemithorax prepared and placed infora full lateral position and the After the general draped possible open thoracotomy. we estimating location of the pleural space problem, aspirate the fluid collec¬ tion at the site of the proposed primary intercostal access with a spinal needle before performing the intercostal incision. Once the appropriate initial site of intercostal access is determined, our practice is to digitally explore this initial intercostal entry site before introducing trocars for the thoracoscope or endosurgical instru¬ then mentation. This VATS approach to empyema and hemothoraces usually re¬ quires two to four intercostal access sites for proper endoscopic vi¬ sualization and instrument manipulation. After entering the pleu¬ ral cavity with the thoracoscope, we remove a sample of the pleural exudate or coagulum for culture, Gram stain, and fungal stains. The use of an "operating" thoracoscope can greatly facilitate the initial of the pleural space (Karl Storz, America; Culver City, exploration Calif). All subsequent intercostal access is achieved under direct thoracoscopic vision to avoid injury to the underlying lung paren¬ chyma. Direct in-line suctioning of the cavity contents and limited lysis of thin adhesions can be accomplished through the biopsy/ suction channel ofthis instrument. After lysis of these adhesions, the limits of the pleural space can be defined more accurately so that subsequent sites of pleural access are created without potential in¬ jury to the lung. Endoscopic forceps, scissors, and retractors are introduced under direct video guidance in strategically located in¬ tercostal access sites to break down the remaining loculations and remove loose fibrinous material within the pleural cavity (Fig 3, 4). We routinely use a special, large-bore suctioning device (SnowdenPencer Inc; Tucker, Ga) to evacuate the pleural exudate and/or clots that are within the chest. Alternatively, a standard 36F Silastic chest tube can be connected to the suction tubing to provide a large-bore 20 Figure 4. Illustration depicting the importance of accurate inter¬ costal access for VATS intervention on loculated pleural effusions. suctioning system. When necessary, a limited decortication of fibrinous pleural peels can be accomplished using standard or en¬ dosurgical instrumentation. However, the thoracoscopic recogni¬ tion of a significant "organized" fibrotic pleural peel associated with trapped lung should lead the surgeon to convert to an open thora¬ cotomy to adequately decorticate the lung. We also try to avoid disturbing broad areas of dense pleural symphysis when performing the lysis ofoffendingpleural adhesions. Such areas are rarely the cause of pulmonary parenchymal entrap¬ ment. However, when it is necessary for adequate decortication of the lung and obliteration of the pleural space, we use an extrapleural dissection to free the lung in these areas. This dissection can often be accomplished using the VATS approach; however, one must also be prepared in these circumstances to convert to open thoracotomy when technical difficulty precludes an adequate dissection. After lysing the adhesions causing the loculations and evacuating the pleural space, we routinely obtain thoracoscopic biopsy speci¬ mens when the cause of the pleural process is in question. The large samples of pleura that are obtained can facilitate the diagnosis of occult infectious agents (ie, tuberculosis) or an underlying malig¬ nancy responsible for the primary pleural effusive process (Fig 5). Once we judge the VATS intervention to be complete, we rou¬ tinely ask the anesthesiologist to reexpand the lung so that we can inspect the adequacy of the decortication and the completeness of the obliteration of the pleural space problem. If we are satisfied with the results of the VATS procedure, strategic placement of chest drainage tubes follows through two of the intercostal access sites. The procedure is terminated with standard closure of all other in¬ tercostal access sites and establishment of 20 cm of negative pres¬ sure suction to the underwater seal chest drainage system. If significant pleural fibrosis/symphysis with pulmonary entrap¬ ment is identified at VATS exploration, conversion to an open pro¬ cedure is indicated. When the conversion to thoracotomy is performed, we maintain the VATS equipment set up on the oper¬ ative field so that continued video assistance can be utilized during the open intervention to facilitate the dissection of hard-to-visual- Downloaded from chestjournal.org on March 30, 2008 Copyright © 1996 by American College of Chest Physicians Clinical Investigations drainage. Bronchopleural fistulas were associated with the space problem in four of the five patients requir¬ ing delayed open drainage procedures. These residual fistulas pleural spaces and peripheral bronchopleural 2 10 resolved between and weeks after eventually for all hospital discharge patients (n=14) with these postoperative VATS problems. Procedural-related VATS complications were un¬ common; however, two patients did have inadvertent diaphragmatic injury during the creation of intercostal access. One of these patients experienced moderate bleedingof that required conversion to thoracotomy for the repair diaphragmatic injury and a peripheral liver parenchymal injury. The other patient did not require any specific management beyond standard wound closure and establishing an alternative site for intercostal access, as the small nonbleeding right-sided injury was located posteriorly in the costophrenic sulcus. Five patients (6.6%) with empyema died after their Figure 5. Illustration of VATS pleural after evacuation of the empyema space. ize areas in the apex of the chest and the biopsy being performed costophrenic recesses.L' Results Of the 76 patients with complex empyemas in this series, 63 (83%) were treated solely with thoracoscopic and decortication of fibrinous drainage, adhesolysis,Thirteen visceral pleural peel. patients (17%) required conversion to open procedures after the VATS proce¬ dure. This included 12 of the 26 (46%) patients with chronic empyemas known to be present for greater than 3 weeks. Immediate conversion to thoracotomy for decortication was performed in seven patients with obvious trapped lung and chronic fibrotic pleural peels. Five patients with chronic space problems persisting after the VATS intervention were treated with local rib resection and empyema tube drainage in four patients and the creation of an Eloesser flap for long-term open A final patient with a postop¬ drainage in one patient.underwent a delayed thoracot¬ erative space problem decortication. to omy accomplish Sixty-seven patients had their chest tubes removed at 3.3±2.9 days, and 9 patients (12%) were sent home with empyema tubes. Persistent peripheral bronchopleural fistulas were present in seven of the nine pa¬ tients requiring long-term open-tube thoracostomy Small residual space problems associated with obvious purulent drainage were present in the other two patients treated with long-term open-tube drainage. intervention as a result of progressive thoracoscopicTwo pneumonias. elderly patients who remained ven¬ tilator dependent after surgery eventually died of pro¬ gressive respiratory failure. Two other patients with significant COPD also died of postoperative pneumo¬ nia. A final patient with autoimmune deficiency syn¬ drome, chronic Pneumocystis, and pulmonary Asalso died of progressive pulmonary sepsis. pergillus The average hospital stay for the 71 patients surviving VATS treatment for empyemas was 7.4±7.2 days. Resolution of the hemothorax was accomplished in all of the 23 patients undergoing VATS management. Chest tubes were removed 2.8±0.5 days postopera¬ tively and hospital stay averaged 4.3±1.9 days. Twen¬ ty-two ofthese 23 patients undergoing VATS survived. One heart transplant patient undergoing VATS for an iatrogenic central venous line placement-related he¬ mothorax died several weeks postoperatively of cardi¬ ac-related causes. Discussion With the advent of effective antibiotic therapies, empyema has become a much less common clinical however, this complication remains an im¬ problem;cause of morbidity and mortality following portant pneumonia or lung resection.6'27 Delays in appropriate referral for surgical drainage of the empyema continue significant prolongation in recovery from these infectious problems and frequently result in the need for more aggressive surgical interventions to correct the pleural process.1"12 Timelyeffusions management of newly identified significant to eradicate the problem pleuralextensive can help is necessary. Our intervention before surgical thoracic to empyemas and hemothopresent approach to cause Downloaded from chestjournal.org on March 30, 2008 CHEST /109 / 1 / JANUARY, 1996 Copyright © 1996 by American College of Chest Physicians 21 MANAGEMENT ALGORITHM FOR EMPYEMA AND HEMOTHORAX PLEURAL EFFUSION t HEMOTHORAX THORACENTESIS GRAM STAIN NEG t OBSERVE ^ GRAM STAIN POS T TUBE ^ ^CHESTTUBE 1 resolution] increasing FLUID RESOLUTION NO resolution rrscj (CT SCAN) VATS EXPLORATION/ XPLOI DEBRIDEMENT X I1-' RESOLUTION OPEN DRAINAGE/ DECORTICATION Algorithm of management for jpleural effusions and hemothorax (modified from Ashbaugh DG). Figure 6. Fig¬ depictedtointhese is aimed at minimizing hospital stay pleural problems and surgical morbidity for these patients. As outlined, we initially approach significant parapneumonic pleu¬ ral fluid collections with thoracentesis. This is followed tube thoracostomy drainage if the process recurs or by if frankly purulent fluid is identified. Accurately posi¬ tioned tube thoracostomy drainage is usually success¬ ful in controlling early "free-flowing" empyemas.28"32 These data support the use of the VATS approach in the management of the "fibrinopurulent" phase of empyema. Indeed, 49 of the 50 patients with empye¬ mas in the fibrinopurulent phase were successfully treated with the VATS intervention alone. This fibrin¬ of empyema is usually characterized opurulent phase by disease chronicity of several days to a few weeks. Exudative pleural fluid and numerous adhesions re¬ sulting in loculation of the effusive process are seen. The VATS approach is well suited for the evaluation of these problems, breaking down the areas of loculation, and completely evacuating the gelatinous exudate from the pleural space. Fibrinous peels can usually be removed from the visceral pleural surface to free any early lung entrapment. A unilocular process is ulti¬ that can be obliterated with strategi¬ mately obtained chest tubes and subsequent full expansion cally placed of the lung at the termination of the procedure. Empyemas that have reached the "organized" phase are characterized by the presence of a thick pleural peel causing varying degrees of pulmonary parenchymal entrapment. These processes are usually found to be several weeks old when the patient's clinical history is carefully reviewed. Customarily, rib resection and empyema tube drainage, long-term open drainage, or races ure is summarized by the algorithm 6.7 This flexible management scheme 22 formal thoracotomy and decortication have been re¬ these organized empyemas. Limited quired to manage and muscle flap rotation are also needed thoracoplasty in some instances to obliterate the pleural space The decision to choose one or the other problem.33,34 of these approaches has largely depended on the pa¬ tient's physiologic reserve and the extent of the parenchymal entrapment present. pulmonary Once the empyema has progressed to this chronic, organizing phase, VATS is often unsuccessful as the primary management because the thick visceral pleu¬ ral peel makes decortication difficult. Although thora¬ cotomy is usually needed to accomplish this procedure, is lost by beginning the intervention with an nothing initial VATS exploration. Many of these more estab¬ lished empyemas will not have yet progressed to the fibrotic phase, as evidenced by the fact that 14 of 26 of chronic empyemas (54%) were successfully managed with VATS alone. The need for open decortication of the lung can be determined by the experienced surgeon at the time of this initial VATS exploration of the empyema. The VATS exploration can also help in the most appropriate site for the thoracot¬ identifying incision to approach the empyema and lung en¬ omy trapment. VATS is also a reasonable first step, or ancillary maneuver, when limited open drainage procedures are chosen for the physiologically impaired patient with empyema. Visualization and breakdown of the deeper within the organized pleural process can lead pockets to more accurate placement of the "open" drainage catheters. Additionally, postoperative irrigation of the empyema can be facilitated with VATS-directed place¬ ment of the chest drainage catheters.15"17 The division of pleural adhesions and the attempted removal of the visceral pleural rind encountered dur¬ ing the VATS intervention can lead to pulmonary pa¬ renchymal injury and significant peripheral postoper¬ ative bronchopleural fistulas. Chronic air leak and prolonged space problems may result if obliteration of the pleural space is not achieved at the end of the Such pleural space problems occurred in procedure. 14 of our patients, which caused the need for long-term tube thoracostomy drainage or for delayed "open" drainage procedures. Although this frequency of post¬ operative air leak and pleural space problems is simi¬ lar to that seen following open procedures, mature surgical judgment must be exercised when solely rely¬ ing on the VATS approach so that unnecessary mor¬ bidity and delays in the patient's recovery from the empyema can be avoided. The VATS approach is also an effective minimally invasive means of definitively addressing significant hemothoraces persisting after attempted tube thora¬ costomy drainage. Although others have described the use ofthe VATS approach in the short-term evaluation Downloaded from chestjournal.org on March 30, 2008 Copyright © 1996 by American College of Chest Physicians Clinical Investigations and treatment of selected cases of blunt and penetrat¬ ing thoracic trauma,35"40 we do not report any experi¬ ence with such VATS applications. We do believe that the use of VATS should be considered early in the management of significant retained hemothoraces to avoid the problems of late fibrothorax or secondary infection within the intrathoracic clot. In summary, VATS appears to be an effective initial management for most complex pleural empyemas and hemothoraces. Excellent visualization of the pleural cavity permits drainage of loculated fluid, removal of fibrinous material, and the ability to perform limited decortication of the lung. Early referral for this mini¬ mally invasive surgical intervention can assist in con¬ the fibrinopurulent phase of empyema before trolling it progresses to the chronic fibrotic phase. However, the surgical team performing VATS must be prepared to convert to open surgical management of the empy¬ ema when it is necessary to achieve the desired ther¬ apeutic end points.41,42 Finally, VATS appears to be an effective alternative to thoracotomy for the manage¬ ment of significant retained hemothoraces after un¬ successful tube thoracostomy drainage. ACKNOWLEDGMENT: We thank Ron Filer for his illustrative assistance in preparing this manuscript. References 1 Lemmer JH, Botham MJ, Orringer MB. Modern management of adult thoracic empyema. J Thorac Cardiovasc Surg 1985; 90: 849-55 2 Bryant LR, Chicklo JM, Crutcher R, et al. Management of tho¬ racic empyema. J Thorac Cardiovasc Surg 1968; 55:850-58 3 Deschamps C, Allen MS, Trastek VF, et al. Empyema following pulmonary resection. Chest Surg Clin North Am 1994; 4:583-92 4 Pothula V, Krellenstein DJ. Early aggressive management of parapneumonic empyemas. Chest 1994; 105:832-36 5 Cham CW, Haq SM, Rahamim J. 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Preliminary report on videothoracoscopy in the evaluation and treatment of thoracic 36 Downloaded from chestjournal.org on March 30, 2008 CHEST /109 /1 / JANUARY, 1996 Copyright © 1996 by American College of Chest Physicians 23 injury. Am J Surg 1993; 166:690-95 McKneally MF. Video-assisted thoracic surgery: standards and Am 1993; 3:345-51 guidelines. Chest Surg Clin NorthMack 42 Landreneau RJ, Hazelrigg SR, MJ, et al. Video-assisted 41 thoracic surgery for pulmonary and pleural disease. In: Shields TW, ed. General thoracic surgery. 4th ed. Philadelphia: Lea & Febiger, 1994; 508-26 AMERICAN COLLEGE OF DC IT E S T PHYSICIANS I ¦National ACCP Review ^Puirpioriary Board 6-10, 1996 June Phoenix, Arizona 6-10, 1996 SeptemberIllinois Chicago, ##«**« ««««»*. FOR INFORMATION CALL: 1 -800-343-ACCP 24 Downloaded from chestjournal.org on March 30, 2008 Copyright © 1996 by American College of Chest Physicians Clinical Investigations Thoracoscopy for Empyema and Hemothorax Rodney J. Landreneau, Robert J. Keenan, Stephen R. Hazelrigg, Michael J. Mack and Keith S. Naunheim Chest 1996;109;18-24 DOI 10.1378/chest.109.1.18 This information is current as of March 30, 2008 Updated Information & Services Updated information and services, including high-resolution figures, can be found at: http://chestjournal.org Citations This article has been cited by 15 HighWire-hosted articles: http://chestjournal.org Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Surgery http://chestjournal.org/cgi/collection/surgery Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://chestjournal.org/misc/reprints.shtml Reprints Information about ordering reprints can be found online: http://chestjournal.org/misc/reprints.shtml Email alerting service Receive free email alerts when new articles cite this article sign up in the box at the top right corner of the online article. 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