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PubMed2005

Major anastomotic dehiscence after repair of esophageal atresia: conservative management or reoperation?

SUMMARY. The authors report a case of recurrent anastomotic dehiscence following surgical repair of type C esophageal atresia according to the Gross classification. Surgical repair was followed by a recurrence, which was successfully managed with conservative treatment. Esophageal atresia with fistulization of the lower pouch in a male newborn with the VACTER association was repaired with a high-tension single-layer anastomosis. On the fifth postoperative day, major anastomotic dehiscence (> 4 mm) was diagnosed. The breach was re-sutured and the anastomosis reinforced with fibrin glue, but dehiscence recurred again 4 days later. Surgery was deferred and the infant was treated conservatively with continued chest-tube drainage and total parenteral nutrition. After 43 days, complete closure of the anastomosis was documented. Even major anastomotic dehiscence can be successfully managed with conservative treatment (chest-tube drainage, suspension of oral feedings, total parenteral nutrition). If the patient is otherwise stable, we feel that this approach should be attempted even when major leakage is present.

Anastomosis, Surgical↗
PubMed1996

[Talc pleurodesis in recurrent malignant pleural effusion--a prospective follow-up study].

Talc pleurodesis was performed in a prospective trial in 38 patients with recurrent malignant pleural effusion. After insertion of a chest tube a slurry containing 8g of iodined talcum, 0.5 ml of 1% xylocain/kg/body weight, and 80 ml of 0.9% NaCl was administered and suction drainage was performed. The chest tube could be removed after 4 +/- 1.7 days. A successful therapy could be achieved in 33/38 patients (86.8%). 2 patients (5.3%) suffered from recurrent pleural effusion which only in 1 case had to be drained. 3 patients died within the first month after talc pleurodesis due to an advanced cancer stage. Complications did not come to evidence in any case.

Adult↗
PubMed2000

Congenital cystic adenomatoid malformation in the newborn: two case studies and review of the literature.

Congenital cystic adenomatoid malformation (CCAM) is a congenital malformation of the lung that can present on imaging studies as abnormal air, air/fluid-filled cysts, or fluid-filled/solid-appearing cysts. The use of ultrasound in prenatal management has increased the number of cases diagnosed in utero. Early diagnosis is vital in the medical management of CCAM. Outcome varies from hydrops and fetal demise to complete resolution before birth. Many CCAMs diagnosed in utero may decrease in size even if substantial mediastinal shift and lung compression are noted at the time of diagnosis. Once the disorder has been diagnosed, use of serial ultrasound is helpful in providing medical management of the fetus. Two cases of CCAM in the newborn are presented that reflect characteristic clinical features but with distinctly different outcomes, one patient successfully responding to resection and ventilatory support, the other succumbing in the first day of life. The embryology, histology, prenatal and postnatal clinical presentation, and treatment of this malformation are discussed on the basis of a review of the literature. Recent developments in fetal diagnosis and treatment, including fetal surgery, are also presented. We conclude that CCAM should be considered in the differential diagnosis in the presence of respiratory distress and mediastinal shift. It is especially important for respiratory therapists, nurses, and other members of neonatal transport teams to consider CCAM in the differential diagnosis for any patient who presents with respiratory distress and a chest radiograph showing mediastinal shift. The treatment of choice for this lesion is surgical resection by either segmentectomy or lobectomy. Even in cases of relatively asymptomatic patients with CCAM, surgical resection should be considered because of the reported association of carcinoma and unresected CCAM. (IO2)) of 1.0 at a rate of 60-100 breaths per minute, there was slight improvement in oxygen saturation, to 50-70%. The postintubation radiograph showed bilateral haziness, with a mediastinal shift to the right. An umbilical venous catheter was placed and a venous blood gas study revealed a pH of 6.82, partial pressure of carbon dioxide of 100 mm Hg, and partial pressure of oxygen of 36 mm Hg. A needle aspiration of the left chest wall was performed to relieve the mediastinal shift; it produced approximately 40 mL of clear fluid. A repeat chest radiograph showed a possible pneumothorax on the left and continued mediastinal shift. A left-side chest tube was inserted and clear fluid continued to drain, but an additional chest radiograph was unchanged. Needle aspiration was then performed on the left side, and a large amount of air was removed. The S(pO2) increased to 88%, and the heart rate and blood pressure remained stable. The patient was then prepared for transport and placed on a Biomed MPV 10 (Bio-Med Devices, Guilford, Connecticut), intermittent mandatory ventilation rate 120, peak pressure 25 cm H(2)O, positive end-expiratory pressure 5 cm H(2)O (25/5), and F(IO2) 1.0. A venous blood gas study just before transport showed a pH of 7.1 and a P(CO2) of 45 mm Hg. The S(pO2) at that time was between 60% and 70%. To facilitate ventilation during transport, the patient was also given pancuronium (Pavulon) and morphine. On arrival at the neonatal intensive care unit, the patient was placed on a Sensormedics High-Frequency Oscillator (Sensormedics Corporation, Yorba Linda, California) with an initial amplitude of 70, airway pressure 25 cm H(2)O, inspiratory time 33%, Hertz 13, and F(IO2) 1.0. Three additional chest tubes were placed in the left hemithorax, which initially evacuated air, followed by serosanguineous fluid. The S(pO2) briefly increased to above 90%. A repeat chest radiograph again showed persistence of the left-sided collection of air and mediastinal shift. (ABSTRACT TRUNCATED)

Autopsy↗
PubMed1993

The technique of small-catheter pleural aspiration. A new, less invasive method for draining pneumothoraces.

Small-catheter aspiration may be preferable to chest tube drainage in many patients with primary spontaneous or iatrogenic pneumothoraces, as well as in some patients with pneumothoraces resulting from minor trauma. It is also less invasive than chest tube drainage, allows greater control over the rate of air removal, and produces less patient discomfort. Following administration of a local anesthetic, the catheter can be inserted into the pleural space using either a trocar or modified Seldinger technique. Addition of a Heimlich valve (with or without a suction device) permits continued air removal. Complications are infrequent and generally minor.

Catheterization↗
PubMed1988

Postbiopsy pneumothorax: estimating the risk by chest radiography and pulmonary function tests.

Pulmonary function tests and chest radiographs of 160 patients who had had percutaneous needle biopsy of lung lesions were reviewed to determine the value of these examinations in estimating the risk of postbiopsy pneumothorax. Chest radiographs were evaluated subjectively for changes of obstructive and restrictive airway disease and for size and depth of lesion. Pulmonary function tests, consisting of simple spirometry (forced vital capacity, percentage of predicted forced vital capacity, forced expiratory volume in 1 sec, percentage of predicted forced expiratory volume in 1 sec, and [forced expiratory in 1 sec/forced vital capacity] X 100), and the pulmonologist's interpretation were evaluated. Pneumothorax developed in 46% (31/67) of patients who had obstructive airway disease according to the results of pulmonary function tests and in 42% (34/81) of those who had obstructive airway disease according to changes on chest radiographs, compared with 19% (10/53) and 25% (17/67) of those who had normal pulmonary function tests and chest radiographs, respectively. Pneumothorax developed in 46% (23/50) of patients who had findings of obstructive airway disease on both pulmonary function tests and on chest radiographs, compared with 7% (2/28) of patients who were classified as normal by both criteria. None of the patients who had normal pulmonary function tests required placement of a chest tube, whereas 19% (13/67) of those who had obstructive airway disease required chest tubes. Decreasing size of lesion and increasing depth of lesion were associated with a significant increase in the risk of pneumothorax. We conclude that the results of chest radiographs and pulmonary function tests are useful parameters for estimating the risk of postbiopsy pneumothorax.

Adult↗
PubMed2006

A method for chest drainage after pediatric cardiac surgery: a prospective randomized trial.

OBJECTIVES: The purposes of this study were to evaluate the clinical safety and efficacy of 10F, 15F, and 19F Blake drains (Ethicon, Sommerville, NJ) in a pediatric population after cardiac surgery and to compare their clinical effect with that of conventional chest drains. METHODS: From January 2002 through December 2004, a prospective randomized trial was conducted on 189 patients who underwent surgical intervention for congenital heart disease at our institution. Statistical analyses were conducted to test the null hypothesis that there was no difference in the incidence of pericardial or pleural effusion requiring drainage. Secondary end points included total volume of drainage, drain size, and time to drain removal. RESULTS: Ninety-eight patients (group A) received Blake drains, and 91 patients (group B) received conventional chest drains. There were no statistically significant difference in age, weight at the time of surgical intervention, open- and closed-heart procedures, and number of drains applied. Statistically significant differences were detected in the frequency of pericardial effusion (group A: 1.1% vs group B: 4.8%, P < .01), pleural effusion (group A: 1.1% vs group B: 5.3%, P < .01), size of the drain (group A: 12.37 French +/- 1.72 French vs group B: 16.81 French +/- 0.70 French, P < .001), and time to removal (group A: 43.75 +/- 20.76 hours vs group B: 55.62 +/- 26.48 hours, P < .001). CONCLUSIONS: Blake drains are safer and more efficient than conventional chest tubes in pediatric populations after cardiac surgery. In comparison with conventional chest tubes, they showed fewer occurrences of effusions and the same amount of fluid drained but smaller size and earlier removal.

Cardiac Surgical Procedures↗
PubMed1978

Urinothorax following blunt trauma to the kidney.

A case of urinothorax is reported in a 19-year-old girl with multiple injuries sustained in an auto accident. Thus blung injury to the right kidney was followed 8 days later by reduced urinary output and serous chest tube drainage. Intravenous dye injection showed dye in urine and in chest tube fluid, and the macerated right kidney was removed. The right pleural effusion then cleared with further drainage. The mechanism by which urine is transferred across the intact diaphragm is thought to be lymphatic drainage.

Adult↗
PubMed2006

The use of recombinant activated factor VII for refractory bleeding post complex cardiothoracic surgery.

We reviewed the outcome following use of recombinant activated factor VII (rVIIa) in patients with major bleeding post cardiothoracic surgery in our unit between January 2002 and July 2004. The unit consists of 16 cardiothoracic intensive care beds in a public metropolitan teaching hospital which serves as a referral centre for heart and lung transplant surgery. Patients with refractory bleeding following cardiothoracic surgical procedures who were treated with rVIIa were identified. A total of 12 episodes of rVIIa use were recorded in ten patients, including three episodes with ventricular assist devices, and 5 heart and/or lung transplants. The median dose used was 85 microg/kg. Chest tube drainage decreased in all patients following administration of rVlIIa; median chest tube drainage decreased from 445 ml/h to 171 ml/h (P = 0.03). Despite cessation of bleeding, mortality was high when rVIIa was used after more than 24 hours. In six episodes, despite early rVIIa use (within six hours), continued bleeding necessitated return to theatre, where a surgical source of bleeding was found. In this small retrospective study, rVIIa significantly reduced bleeding that was refractory to standard blood product transfusion. In this series of patients, those that did not respond to rVIIa early in the postoperative phase were found to have a surgical source of bleeding.

Adult↗
PubMed1997

[Effects of aprotinin on blood loss reduction in children undergoing repair of tetralogy of Fallot].

The effect of aprotinin on the blood loss reduction was studied in children undergoing repair of tetralogy of Fallot. We administered aprotinin to consecutive 21 patients during the repair of tetralogy of Fallot and examined the blood loss and operative time in comparison with that in a control group of 20 patients. 30,000 KIU/kg of aprotinin was infused as the initial cardiopulmonary bypass (CPB) dose and 10,000 KIU/kg/hr was continuously administered as the maintenance dose during CPB. There was no resternotomy case due to bleeding and no operative death in both groups. Blood loss after CPB during operation and total blood loss during operation were significantly lower in aprotinin group than in control group. There were no differences between two groups in the volume of chest tube drainage in the postoperative 24 hours and the duration of chest tube drainage. Time from cessation of CPB to skin closure and total operative time were significantly shorter in aprotinin group than in control group. In conclusion, aprotinin was effective on the reduction of blood loss and the shortening of operative time in children undergoing repair of tetralogy of Fallot.

Aprotinin↗
PubMed2005

Percutaneous treatment of high-output chylothorax with embolization or needle disruption technique.

Surgical ligation of the thoracic duct is associated with a high degree of morbidity; therefore, a minimally invasive approach is desirable. Herein, eight percutaneously treated patients are described. In four patients, the thoracic duct was embolized with use of coils and glue. In the other four patients, lymphatic ducts were disrupted by multiple needle punctures. The median chest tube drainage substantially decreased in both patient groups from more than 1,300 mL the day before the procedure to less than 300 mL 2 days after the procedure. The median times to chest tube removal were 7 days in the embolization group and 3.5 days in the needle disruption group.

Adhesives↗
PubMed2006

Intrapleural hypotonic cisplatin treatment for malignant pleural effusion in 80 patients with non-small-cell lung cancer: a multi-institutional phase II trial.

To assess the effect and toxicity of hypotonic cisplatin treatment (HPT) consisting of the intrapleural administration of cisplatin in distilled water for malignant pleural effusion in patients with non-small-cell lung cancer (NSCLC). Non-small-cell lung cancer patients with cytologically proven and previously untreated malignant pleural effusion were enrolled into this study. Firstly, the lung was fully re-expanded by a tube thoracostomy, and then 25 mg cisplatin in 500 ml of distilled water was instilled through a chest tube and then the tube was clamped. After 1 h, the tube was declamped and allowed to drain. The chest tube was removed when the pleural effusion volume decreased to 200 ml or less per day. A complete response (CR) was considered to occur when the pleural effusion disappeared. A partial response (PR) was determined to occur when the volume of pleural effusion remained under (1/4) of hemithorax. The response at 4 weeks was evaluated by an extramural review. Out of 84 patients enrolled from February 1998 to August 2002, 80 patients were eligible and analysed in the present study. The toxicity of HPT was acceptable. Neither a haematological toxicity of any grade nor grade 4 nonhaematological toxicity was observed. Grade 3 nonhaematological toxicities were observed, including nausea (4%), vomiting (3%), pyothorax (1%) and dyspnoea (1%). The median time of drainage from HTP was 4 days. Twenty-seven (34%) and 39 (49%) patients achieved CR and PR, respectively, for an overall response rate of 83% (95% confidence interval, 74-91%). The median duration of the response was 206 days. The median survival time of all patients was 239 days. Hypotonic cisplatin treatment for malignant pleural effusion of NSCLC is therefore considered to be feasible and effective. A phase III study of HPT is thus warranted.

Adult↗
PubMed1982

Treatment of pneumothorax, pneumopericardium and pneumomediastinum.

Fifty-four patients with pneumothoraces were treated by tube thoracostomy. Three of these also suffered from pneumomediastinum, two from pneumopericardium, and one from pneumoperitoneum. Except for 2 pneumomediastina, all of these were drained. A chest drain was inserted after chest radiography or transillumination and/or localization of the extrapulmonary air by fine needle aspiration. The drain was placed surgically at the highest point of air accumulation, after creation of a long subcutaneous tunnel and perforation of the intercostal space by blunt dissection. Pressure upon vital structures by pathological air accumulations was relieved in all cases. On a few occasions a tension pneumothorax redeveloped despite there being a chest tube in place, and new chest tubes had to be inserted. No complications due to the procedure were observed.

Adolescent↗
PubMed1996

Re-expansion pulmonary oedema following spontaneous pneumothorax.

Re-expansion pulmonary oedema may occur after chest tube drainage of pneumothorax and can give rise to cardiopulmonary manifestations which range from the mild to the severe. In order to evaluate the prevalence and the clinical manifestations of this complication, all patients with spontaneous pneumothorax managed with chest tube drainage were evaluated over an 8-yr period (1986-1994). A chest radiograph was performed routinely in all patients within 4 h of tube insertion. Lung expansion and the appearance of infiltrates within the lungs were investigated specifically. Re-expansion oedema was noted in three of 320 episodes (0.9%). Two of the three patients needed rapid and extensive clinical treatment.

Adult↗
PubMed2005

Comparison of early postoperative results of thymectomy: partial sternotomy vs. videothoracoscopy.

BACKGROUND: The aim of this study was to compare the early postoperative results of thymectomy operations after partial sternotomy and videothoracoscopy for myasthenia gravis. METHODS: A total of 51 thymectomy operations were reviewed. The surgical procedure was simple thymectomy with partial sternotomy in the first 19 patients (Group I) and videothoracoscopic thymectomy (Group II) in the remaining patients. Both groups were compared in terms of preoperative data (age, gender, classification, duration of disease, medications), operative data (operation time, the mean amount of drainage, the duration of chest tube drainage), and postoperative data (duration of hospital stay, complications and pain). RESULTS: Groups were statistically uniform in terms of preoperative and operative data. Statistically significant differences were noted for the duration of chest tube drainage (48.8 vs. 29.8 hours, p < 0.001), the amount of drainage (264.4 vs. 178.6 ml, p = 0.001), the length of hospital stay (5.6 vs. 2.3 days, p = 0.000), and the visual analogue scale score (4.8 vs. 3.1, p < 0.001). CONCLUSIONS: Thymectomy with videothoracoscopic surgery demonstrated a more comfortable and faster recovery period without deterioration in myasthenic status.

Adult↗
PubMed1998

Persistent air-leak in spontaneous pneumothorax--clinical course and outcome.

Persistent air-leak in patients with spontaneous pneumothorax (SP) is not uncommon and may present a management dilemma in those who are unfit or unwilling for surgery. Video-assisted thoracoscopic surgery (VATS) has been advocated in the management of patients with broncho-pleural fistulae (air-leak persisting beyond 7 days): however the optimum time for surgical intervention remains unclear. We reviewed the records of 130 episodes of SP in 115 patients over a 2-year period to determine clinical course and outcome, particularly with respect to duration of air-leak. There were 90 first episodes and 40 recurrent episodes. Eighty-one episodes (62%) occurred in patients with underlying lung disease (secondary pneumothorax). Initial management consisted of chest-tube drainage in 104 episodes (80%) occurring in 90 patients, percutaneous needle aspiration in five patients (4%) and observation in 21 episodes (16%) in 20 patients. In the group treated with chest-tube drainage, there was spontaneous resolution of air leak and lung re-expansion in 90 episodes (87%). The overall incidence of broncho-pleural fistula was 34.6%. In the primary SP group. 75% of air-leaks ceased by 7 days and 100% by 15 days. In the secondary SP group, 61% of air-leaks resolved by 7 days and 79% by 14 days, after which time resolution of air-leak proceeded at a much slower rate. Five patients underwent surgery while nine patients were discharged with residual pneumothoraces. There were no major complications or mortality. Based on our findings, we advocate surgery for patients with air-leak persisting beyond 14 days, while favouring a conservative approach before this time, as the majority of air-leaks (especially in patients with primary pneumothorax) would resolve by 14 days.

Adult↗
PubMedDate not supplied

Prehospital needle aspiration and tube thoracostomy in trauma victims: a six-year experience with aeromedical crews.

The use of prehospital tube thoracostomy (TT) for the treatment of suspected tension pneumothorax (TPtx) in trauma patients is controversial. A study is presented that reviews a 6-year experience with the use of needle catheter aspiration (NA) and chest tubes performed in the field by air medical personnel. Prehospital flight charts and hospital records from 207 trauma patients who underwent one or both of these procedures in the field were retrospectively reviewed. The clinical indications used to determine treatment are presented for both procedures. Improvement in clinical status of patients observed by flight personnel were similar for both treatment groups (54% for NA, 61% for TT). Thirty-two (38%) of the TT patients had failed NA attempts prior to chest tube placement. Average time on scene (T.O.S.) was significantly greater for the TT group (25.7 min versus 20.3 min for NA group). Fewer patients were pronounced dead on arrival (D.O.A.) with TT treatment compared to NA alone (7% versus 19%, respectively). Injury severity scores, number of hospital complications, length of stay (L.O.S.), and total hospital costs were not different between the two groups. There were no cases of lung damage or empyema formation associated with prehospital TT treatment. Overall mortality was similar for both groups. From these data, we conclude that NA is a relatively rapid intervention in the treatment of suspected TPtx in the prehospital setting; however, TT is an effective adjunct for definitive care without increasing morbidity or mortality. A better understanding of the physiology of intrapleural air masses is needed to determine the most effective decompression requirements prior to aeromedical transport.

Adolescent↗
PubMed2002

Cerebral arterial gas embolism following diagnostic bronchoscopy: delayed treatment with hyperbaric oxygen.

PURPOSE: To describe a clinical scenario consistent with the diagnosis of cerebral arterial gas embolism (CAGE) acquired during an outpatient bronchoscopy. Our discussion explores the mechanisms and diagnosis of CAGE and the role of hyperbaric oxygen therapy. CLINICAL FEATURES: A diagnostic bronchoscopy was performed on a 70-yr-old man who had had a lobectomy for bronchogenic carcinoma three months earlier. During the direct insufflation of oxygen into the right middle lobe bronchus, the patient became unresponsive and developed subcutaneous emphysema. Immediately, an endotracheal tube and bilateral chest tubes were placed with resultant improvement in his oxygen saturation. However, he remained unresponsive with extensor and flexor responses to pain. Later, in the intensive care unit, he exhibited seizure activity requiring anticonvulsant therapy. Sedation was utilized only briefly to facilitate controlled ventilation. Investigations revealed a negative computerized tomography (CT) scan of the head, a normal cerebral spinal fluid examination, a CT chest that showed evidence of barotrauma, and an abnormal electroencephalogram. Fifty-two hours after the event, he was treated for presumed CAGE with hyperbaric oxygen using a modified United States Navy Table 6. Twelve hours later he had regained consciousness and was extubated. He underwent two more hyperbaric treatments and was discharged from hospital one week after the event, fully recovered. CONCLUSION: A patient with presumed CAGE made a complete recovery following treatment with hyperbaric oxygen therapy even though it was initiated after a significant time delay.

Aged↗
PubMed2003

A new sterilization technique with balloon-tube thoracostomy for thoracic empyema.

OBJECTIVE: Failure or prolongation of treatment for refractory thoracic empyema by the current chest-tube drainage technique is often due to sterilization difficulties. Insufficient sterilization prolongs hospitalization, and is often associated with life-threatening complications and/or additional invasive surgical procedures. A new chest-tube sterilization technique aimed at making it less invasive and shortening the therapy is proposed. METHODS: Following pretreatment for complications including loculation, bronchopleural fistula, or corticated lung, a double-lumen trocar catheter was introduced at the bottom of the empyemic cavity through the lateral chest wall. Then, a Foley balloon urethra-catheter was inserted and attached just inside the anterior chest wall at the top of the cavity for the evacuation of intrathoracic air. After irrigation of the cavity with distilled water once or twice, the cavity was completely filled with a bactericidal solution which was left in place for 30-60 minutes, followed by an antibiotic solution for more than 20 hours. RESULTS: Among the five treated post-lobectomy or pneumonectomy cases, sterilization was obtained after only one treatment in four cases and after two courses in the other. Catheterization duration from the initial treatment was 2-13 days. Neither recurrence nor treatment-related major complications were observed. CONCLUSIONS: This balloon-tube thoracostomy technique is simple, minimally invasive and cost-effective, due to shortening of the treatment time with minimal manpower and equipment requirements. It is thus a promising therapeutic approach to thoracic empyema and has the potential for application to other intrathoracic disorders.

Aged↗