91. A further case of (left-side) thoracoplasty

Thoracopas 50 years ago
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These operations were a last resort, and have, as a result of advances in lung surgery and tuberculosis-therapy, largely disappeared. One can imagine that these methods were especially “interventional”. The effectiveness was once upon a time described as good. In addition, our recent observations included no mention of any protest or opposition.

Calcification thorax wall diff pleura
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92. On account of general completeness, we would like to show here an unusual form of thorax calcification.

Where is it localised? What illness can the 72-year old patient (a lady) have endured?
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The question is not fair. Because, first and foremost we ought to question and examine the patient.
Medical condition: in strict accordance with “Ablatio mammae.” Condition after a secondary period of healing and infection of the thorax wall. Calcification in the thinned-out and scarred soft tissue area above the ribs:
Calcification in a scarred plate area.

In the following text we are going to address two topics which enjoy a significantly clinical significance (This is after the rare incidences of oleothorax)
-    Pleural empyema (these alone, therefore, are so very important , because they do represent serious illnesses with a high letality rate) as well as .......
-    pleural differential diagnosis and pulmonary space demands.

Till now, we have concerned ourselves with only chronic empyeman. Our cases 40-75 were all almost those of empyema  - at least in the widest sense. But there were organisational shapes, clinically silent, or indeed reactivated. The message was: these “Light classifications III” display a false sense of peace:
now, let us turn to the acute shapes,
those of Light classification I and II .

Pleural scar
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93. Three drained empyemata.  
Downward sedimentation of the Leukozyten. Separation of of the cellular and interstitial components.

How serious is pleural empyema? Is the treatment quite simple?
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Two important remarks about Pleural empyema.
-    Pleural empyemata are very serious and very grave illnesses  (in certain situations and hospitals, the lethality rate is currently standing at 50%, but this should improve )
-    The therapy  is very difficult (complicated localisation results in a difficult possibility of full drainage).

These represent the most serious statements in my speech. Patients lose their lives because these experiences are so widespread and so widely-underestimated.

Empyema difficult puncture
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94. Why does the localisation vary so strongly? Why, for that reason, is the therapy so very difficult? Explain it on the basis of the case presented.
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The localisation of the empyema is, due to the (already existing) pleural adhesions, especially multi-shaped. -

As to this patient, the empyema gathers itself in an “interlobar” fashion and in the dorsal paravertebral region. Without a CT or without an ultrasound, a sufficient point is quite hopeless. Even with the support of an image, it remains “art in the extreme.”
A single drainage is overwhelmingly insufficient. Even in a good state of a Drainage-value (from a larger diameter), it quite often transpires that, due to the tenacity and the coagulation aspect, the material enjoys no total aspiration at all.
It is necessary to form a surgical team with a committed and patient attitude. The surgeon enriches us with his experience in mini-thoracotomy and pleuroscopy. The radiologist performs the decisive elements during the translation of the images in the situation as concerns the “situs. I see no chance for either the radiologist or indeed for the surgeon.

Pl-Empyema ais phenomenon
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95. What differentiates the left from the right picture  ?
In the past fortnight, the patient has suffered from a very serious lung infection. In spite of improved infiltrates in the lung parenchyma, there are still signs of more pronounced infection, more pronounced illness sensation with fever and tickling in the throat.

(Click here for the answer)

- The slice to the left lies in a more cranial manner
- Contrast is given intravenously.The decisive difference in effect: the left is significantly small, the right is sufficient.
- Diagnosis: pleural emyema following pneumonia.
    - Enhancement of both pleurae.
- A thin, fatty layer between the pleura parietalis and the thorax inner wall.
- The fact that this layer is only thin is an important sign for acute pleural empyema and permits a differentiation between chronic, persistent effusions with their wide fat strips.
(even the plombage , 76-92, have – generally- these thin, fat-rich layers. But history was different in this case)

-    After diagnostic drainage, some air was to be found in the pus. This air gradually increased to the highest point of the caverns. Gradually the air, after 15 minutes, became ensnared in the pus.  The tenacity of these suppurative materials proved this to be the case.
I maintain the following: the probe incision from 1 milligram air (or 1 milligram CM) is especially informative about the possible or indeed impossible draining capability. It is, therefore, lawful, especially if one is classified or graded by many as useless and risky. The information bonus and benefit is colossal and quite possibly, life-saving.

From a sonographic aspect, quite often the impression of “septa” within the empyema can exist.  We don’t know whether it may be a fact or an artefact.
Indisputable fact: air which is not distributed (i.e. “trapped air') as well as the sonographic impression of septa actually represent alarm signals for a very grave condition. A difficult drainage is potentially inadequate.