A 26-year-old patient with a voluminous primary pulmonary hemangiopericytoma in the right lung, diagnosed through previous surgical biopsy, presented irreversible cardiac arrest during the hilar dissection portion of a right pneumonectomy. The patient did not respond to resuscitation efforts. Autopsy showed total obstruction of the mitral valve by a tumor embolism. In cases of large lung masses with hilar involvement, as in the case presented, we recommend preoperative evaluation using transesophageal echocardiography, magnetic resonance imaging or angiotomography. If injury to the pulmonary vessels or atrial cavities is detected, surgery with extracorporeal circulation should be arranged in order to allow resection of the intravascular or cardiac mass, together with pulmonary resection. We recommend that care be taken in order to recognize and treat this problem in patients not receiving a preoperative diagnosis.

Keywords: Embolism; Heart arrest; Pneumonectomy.

Objective: Heimlich valve has been described as a substitute for water-sealed drainage systems. The objective of this study by the Thoracic Surgery Service of the "Hospital das Clínicas", University of São Paulo Medical Center, is to assess its effectiveness in the treatment of pneumothorax and its ease of operation, safety, and patient toleration. Methods: From June/97 to August/00, 107 patients with pneumotoraxes of different etiologies were analyzed. The majority (76%) were classified radiologically as suffering from moderate or large pneumothorax, three hypertensive pneumothorax, and one was bilateral. The pleural cavity was drained with teflon or polyurethane plastic pig-tail catheters (10.2F, 14F, straight 11F connected to the Heimlich valve or the valve was connected directly to the thoracic drain in post-thoracotomy patients). Results: The valve remained in place for one to 120 days (mean 4 days). Tolerance to the system was good in 89% of cases. There were no serious complication linked to the system. Associated pleural effusion in 20 patients (18.5%) did not prevent the system from functioning well. Only two patients (1.8%) developed subcutaneous emphysema, and therefore, a 36F Tubular drain under water seal was chosen. Thoracotomy for decortication was indicated in one patient (0.9%). Twenty patients (18.5%) were treated on an outpatient basis. Conclusions: The Heimlich valve confirmed its effectiveness in resolving pneumothorax of different etiologies and in postoperative air leaks. Its operation was simpler than that of conventional systems. The good toleration and safety mentioned by the patients was a determining factor in early hospital discharge and a motive for outpatient treatment.

Keywords: Pneumothorax. Pleura. Postural drainage.

Glomus tumors are uncommon benign soft tissue neoplasms. We report the case of a 32-year-old male who presented with right upper lobe atelectasis due to an endobronchial tumor. The patient underwent right upper lobectomy and wedge bronchoplasty. The pathological diagnosis was bronchial glomus tumor. To our knowledge, this presentation (with right upper lobe atelectasis) has never before been reported. Glomus tumor should be considered in the differential diagnosis of endobronchial lesions causing lobar atelectasis.

Keywords: Glomus tumor; Bronchial neoplasms; Thoracic surgical procedures.

Granular cell tumor (GCT) is a term used to describe a tumor with distinctive histology, characteristic immunohistochemical profile, and peculiar ultrastructural findings. This tumor has an ample topographic distribution and its localization in the airways is considered common. The authors report on the case of a 40-year old woman who had been presenting productive cough and fever for two months and seemed normal at physical examination. Computerized tomography evidenced thickened intermediary bronchial wall and bronchoscopy showed, at this level, hyperemia and elevation of the endobronchial mucosa. Histopathological and immunohistochemical examination of the tissued established the diagnosis of GCT. The purpose of this report is to call attention to the possibility of diagnosing this kind of tumor by small endoscopic biopsies.

Keywords: Neoplasm muscle tissue. Granular cell tumor. Biopsy. Diagnosis

Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia with airflow obstruction is a rare form of lung injury. All of the reported cases have been diagnosed by surgical lung biopsy. Only three of the reported cases presented with diffuse interstitial lung opacities on HRCT scans. We report three additional cases of this entity. All of the patients were female and presented with mild-to-moderate airflow obstruction. In the first case, transbronchial biopsy and imaging data were sufficient to make the diagnosis. Although the HRCT scans of all three cases revealed a mosaic pattern, that of the third patient also revealed diffuse interstitial infiltrate. In extremely rare cases, HRCT findings can simulate those seen in other interstitial lung diseases.

Keywords: Neuroendocrine cells; Carcinoid tumor; Bronchiolitis obliterans.

Objective: To evaluate pleural drainage using a one-way flutter valve following elective lung resection. Methods: This was a prospective study, with descriptive analysis, of 39 lung resections performed using a one-way flutter valve to achieve pleural drainage during the postoperative period. Patients less than 12 years of age were excluded, as were those submitted to pneumonectomy or emergency surgery, those who were considered lost to follow-up and those in whom water-seal drainage was used as the initial method of pleural drainage. Lung expansion, duration of the drainage, hospital stay and postoperative complications were noted. Results: A total of 36 patients were included and analyzed in this study. The mean duration of pleural drainage was 3.0 ± 1.6 days. At 30 days after the surgical procedure, chest X-ray results were considered normal for 34 patients (95.2%). Postoperative complications occurred in 8 patients (22.4%) and were related to the drainage system in 3 (8.4%) of those. Conclusions: The use of a one-way flutter valve following elective lung resection was effective, was well tolerated and presented a low rate of complications.

Keywords: Drainage; Postoperative complications; Thoracic surgery.

Five traumatic late cardiac tamponade cases were analyzed. All patients were male, mean age was 26.2, victims of thoracic penetrating stabbing wound in the precordial region, Ziedler area, admitted to a trauma reference center. They were classified by the Ivatury physiological index for cardiac trauma. The first treatment approach was intercostal pleurectomy and volemic resuscitation followed by hemodynamic and respiratory recovery. Patients with cardiac tamponade symptoms were re-admitted within an interval from eight to twenty four days (mean 20 days) in a thoracic surgery service of a tertiary reference hospital. Diagnostic exams confirmed thickening and pericardial effusion associated with a left pulmonary base entrapment in four of the cases which were treated by posterolateral thoracotomy, including partial pericardiectomy and pulmonary decortication. One patient was diagnosed with purulent pericarditis by supplementary exams and underwent a subxiphoid pericardial drainage. Postoperative cardiac arrhythmia occurred in one patient but the others did not develop any complications and there were no tamponade recurrent cases.

Keywords: Cardiac tamponade. Penetrating wounds. Thoracic injuries. Diagnosis.

Objective: To compare the resistance of manual suture with that of mechanical suture immediately after the suture of the left bronchial stump of dogs submitted to pneumonectomy. Methods: A total of 15 mixed-breed dogs of both genders, each weighing between 8 and 23 kg, were randomly divided into 2 groups. In group I (n = 7), the bronchial stump was sutured manually (the Sweet method) and, in group II (n = 8), it was stapled. Immediately after the closure of the bronchial stump, the intratracheal pressure was progressively increased in a controlled manner. Results: The mean rupture pressure of the bronchial stump suture line was 33.71 mmHg in group I and 89.87 mmHg in group II (p < 0.01). Conclusion: These data allowed us to conclude that mechanical suture of the bronchial stump, submitted to pressure immediately after closure, is more resistant than is manual suture in dogs submitted to pneumonectomy.

Keywords: Comparative study; Suture techniques; Bronchial fistula; Pneumonectomy.

We report the case of a 74-year-old female patient diagnosed with a giant cell tumor of the sternum. The clinical and radiological presentation was indicative of a primary tumor of the sternum. The patient underwent complementary tests and surgery. The pathological examination confirmed the diagnosis. Commonly observed in the long bones of the appendicular skeleton, this type of tumor is characterized by its local aggressiveness and metastatic potential. We also review the literature on the topic.

Keywords: Sternum; Giant cell tumors; Thorax.

A 30 year old Caucasian male from São Paulo was admitted to the hospital He had been complaining about constant, moderate pain in the anterior and lateral left hemi-thoracic region for the last three months as well as associated great effort dyspnea over the last month.Investigation with chest X-rays, CT scans and MRI revealed a large anterior and medial mediastinal tumor suggesting large vessel invasion. The patient was submitted to a left side parasternal mediastinostomy and a biopsy of the mediastinal mass which was complicated by severe bleeding. An immediate median full sternotomy was elected in addition to a left anterior-lateral thoracotomy for total tumor resection and control of the bleeding. Evolution was good, with hospital discharge on the ninth postoperative day. The anatomical-pathological essay disclosed a hemangioendothelioma of the mediastinum.

Keywords: Hemangioendothelioma/diagnosis. Mediastinal neoplasms.