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PubMed2004

Complications associated with the Nuss procedure: analysis of risk factors and suggested measures for prevention of complications.

PURPOSE: Because the Nuss procedure for the correction of pectus excavatum is in its early stage, there have been problems that need to be solved. The authors examined complications in a single-institute experience of the Nuss technique to develop possible solutions to prevent them. METHODS: A total of 335 consecutive patients who underwent the Nuss procedure between August 1999 and September 2002 were studied retrospectively. Median age was 8 years (range, 1 to 46). Two hundred sixty-four patients (78.8%) were in the pediatric group (age < or = 15) and 71 patients (21.2%) were in adult group (age > 15). One hundred ninety-three patients (57.6%) had symmetric and 142 patients (42.4%) had asymmetric pectus configurations. Risk factors predicting postoperative complications were analyzed using multivariate logistic regression. RESULTS: Postoperative complication rate was 16.1% (54 of 335) in total patients. Early complications (within a month) were pneumothorax (n = 23; 6.9%), wound seroma (n = 11; 3.3%), and bar displacement (n = 8; 2.4%). Late complications (after a month) were pericarditis and pericardial effusion (n = 5; 1.5%), bar displacement (n = 4; 1.2%), and hemothorax (n = 3; 0.9%). Techniques were modified to prevent complications especially in bar shaping and fixation, which led to decrease of complication rate in later experience (operation date 1, 29.4%; 15 of 51 v. operation date 2, 12.0%; 34 of 284; P =.004). Grand Canyon type (eccentric long canal type) showed a higher complication rate than other types (40%, 12 of 30 v. 12.1%, 37 of 305; P <.001). Risk factors were analyzed in each group. CONCLUSIONS: Major complications were related to severe eccentric type of pectus configuration (Grand Canyon type) and lack of surgeon's experience (earlier date of operation). Complication rate was reduced with accumulation of experience and advancement of surgical techniques. The Nuss procedure can be performed at a low risk of complications with the current technique.

Adolescent↗
PubMed2005

The minimally invasive Nuss technique for recurrent or failed pectus excavatum repair in 50 patients.

PURPOSE: The aim of this study was to demonstrate the efficacy of the minimally invasive technique for recurrent pectus excavatum. METHODS: Fifty patients with recurrent pectus excavatum underwent a secondary repair using the minimally invasive technique. Data were reviewed for preoperative symptomatology, surgical data, and postoperative results. RESULTS: Prior repairs included 27 open Ravitch procedures, 23 minimally invasive (Nuss) procedures, and 2 Leonard procedures. The prior Leonard patients were also prior Ravitches and are therefore counted only once in the analyses. The median age was 16.0 years (range, 3-25 years). The median computed tomography index was 5.3 (range, 2.9-20). Presenting symptoms included shortness of breath (80%), chest pain (70%), asthma or asthma symptoms (26%), and frequent upper respiratory tract infections (14%). Both computed tomography scan and physical exam confirmed cardiac compression and cardiac displacement. Cardiology evaluations confirmed cardiac compression (62%), cardiac displacement (72%), mitral valve prolapse (22%), murmurs (24%), and other cardiac abnormalities (30%). Preoperative pulmonary function tests demonstrated values below 80% normal in more than 50% of patients. Pectus repair was done using a single pectus bar (66%), 2 bars (32%), or 3 bars (2%). Stabilizers were used in 88% of the patients. Median length of surgical time did not significantly differ from that of primary surgeries. Complications were slightly higher than those in primary repairs and included pneumothorax requiring chest tube (14%), hemothorax (8%), pleural effusion requiring drainage (8%), pericarditis (4%), pneumonia (4%), and wound infection (2%). There were no deaths or cardiac perforations. Initial postoperative results were excellent in 70%, good in 28%, and fair in 2%. Late complications of bar shift requiring revision occurred in 8%. Seventeen patients have had bar removals with 9 patients being more than 1 year postremoval. For the 17 patients who are postremoval, excellent results have been maintained in 8 (47%), good in 7 (41%), fair in 1 (6%), and failed in 1 (6%). There have been no recurrences postremoval. CONCLUSIONS: Although failed or recurrent pectus excavatum repairs are technically more challenging, reoperative correction by the Nuss procedure has met with excellent success.

Adolescent↗
PubMed2005

Ruptured aneurysm of the inferior thyroid artery: repair with coil embolization.

Although pseudoaneurysm of the thyrocervical trunk is seen with increasing frequency as a result of trauma or central venous cannulation, true aneurysm of the thyrocervical trunk is exceedingly rare. A 44-year-old woman presented with acute left neck swelling that progressed rapidly to respiratory distress and subsequent hemothorax. Emergency endotracheal intubation was performed for airway control, and tube thoracostomy was placed for drainage of the pleural space. A review of the literature reveals that this is the second patient known to be successfully treated by arterial embolization of a ruptured aneurysm of the inferior thyroid artery and the fifteenth known case of aneurysm of the inferior thyroid artery. Surgical or endovascular intervention has been successful. Observation has been uniformly fatal. Because life-threatening rupture is possible, the presence of this aneurysm mandates intervention. Endovascular coil embolization is a viable option for treatment of this entity.

Adult↗
PubMedDate not supplied

The endoscopically assisted simultaneous posteroanterior reconstruction of the thoracolumbar spine in prone position.

BACKGROUND CONTEXT: The reconstruction of the anterior column of the thoracolumbar spine has become more common in the last few years, due largely to the unfavorable results of exclusively posterior surgical treatment, which has been associated with a lack of about 10 degrees of kyphosis correction after removal of the instrumentation. The minimally invasive anterior techniques have reduced the morbidity of the anterior approach significantly. PURPOSE: A minimally invasive technique for anterior stabilization of the spine may reduce the morbidity of the open approach. Irrespective of an anterior open or an endoscopic approach, the posteroanterior instrumentation of thoracolumbar fractures requires time-consuming intraoperative maneuvers to change the patient position from prone to lateral. We describe here a standardized anterior endoscopically assisted approach for the segments T4 to L4. This approach allows the patient to remain in prone position. A 4- to 5-cm incision combined with a retractor system is used. STUDY DESIGN/SETTING: In a prospective study, all patients of our clinic who underwent surgery of the thoracolumbar spine between July 1999 and May 2001 were registered. Study criteria were duration of surgery, duration of anesthesia, intra- and postoperative complications. PATIENT SAMPLE: Between July 1999 and May 2001, 42 patients (25 male, 17 female, average age of 41.9 years), who presented with 55 injured spinal levels and underwent surgery of the thoracolumbar spine in prone position, were included. OUTCOME MEASURES: Duration of surgery (posterior/anterior/total), duration of anesthesia, method of instrumentation, intra- and postoperative complications, postoperative hospital stay and radiographs were evaluated. METHODS: Surgery was performed in prone position. A thoracic approach was used for instrumentation of T9 to L2. A retroperitoneal approach was used for stabilization of L1 to L5. Both procedures were endoscopically assisted with a new retractor system (Synframe; Synthes GmbH, Umkirch, Germany). In this manner, only an incision 4 to 5 cm long and a stab incision for the endoscope were required. The whole procedure was performed in prone position without a change of position during surgery. RESULTS: A total of 42 patients underwent surgery following this technique: 14 isolated anterior procedures (median duration of surgery, 181 minutes); 13 simultaneous one-stage procedures (median duration of surgery: 210 minutes) and 15 combined two-stage procedures (median duration of surgery: 90 minutes posterior, 120 minutes anterior, 240 minutes posterior+anterior). In the simultaneous posteroanterior procedures, the anterior instrumentation was performed 20 times using one rod, twice using two rods and in six patients simply by bone grafting. No intraoperative complications were observed. In the postoperative course, one case of pneumothorax, one case of hemothorax and one case of transient intercostal neuralgia occurred. CONCLUSION: The approach to the anterior spine in prone position is feasible by using a self-holding retractor system for the region between T4 and L4. The duration of anesthesia for the one-stage simultaneous procedure was reduced by about 40 minutes, because changing the position of the patient is no longer necessary. The minimal incision, in combination with the retractor system, significantly reduces cost by allowing the use of less expensive instruments and implants. The advantages of the open and the endoscopic techniques are combined, while their disadvantages are minimized. The main advantage of the prone position is the opportunity to access the anterior and posterior spine simultaneously, which is especially helpful in reduction maneuvers.

Adult↗
PubMed2003

Should helical CT scanning of the thoracic cavity replace the conventional chest x-ray as a primary assessment tool in pediatric trauma? An efficacy and cost analysis.

BACKGROUND/PURPOSE: Findings from studies in the trauma literature suggest that thoracic computed tomography (TCT) scanning should replace conventional radiographs as an initial imaging modality. Limited data exist on the clinical utility and cost of TCT scans in pediatric trauma. Our current practice is to obtain TCT scans in those children at risk for thoracic injures. The purpose of this study is to examine what additional information TCT provides, how frequently it results in a change in clinical management, and a cost/benefit analysis. METHODS: Children 18 years old and younger that had both a Chest x-ray (CXR) and TCT scan in their initial workup were included. Indications for TCT scan were (1) any sign of thoracic injury on CXR, (2) pathologic findings on physical examination of the chest, and (3) high impact force to chest wall. A child may have had one or more indications for a TCT scan. RESULTS: Between 1996 and 2000, 45 of 1,638 trauma patients met study criteria. Indications for TCT included thoracic injury on CXR (n = 27), findings on physical examination (n = 8) and high-impact force (n = 33). In 18 of the 45 (40%), injuries were detected with TCT imaging but not on CXR. These included contusions (n = 12), hemothorax (n = 6), pneumothorax (n = 5), widened mediastinum (n = 4), rib fractures (n = 2), diaphragmatic rupture (n = 1), and aortic injury (n = 1). In 8 patients (17.7%) TCT imaging resulted in a change in clinical management. These included insertion of a chest tube (n = 5) aortography (n = 2) and operation (n = 1). Age, sex, injury severity score, mechanism, and indication for TCT could not predict differences between TCT and CXR (P >.05). In our institution, the cost of a TCT is $200, and the patient charge is $906 ($94 per CXR). Based on our study data 200 TCTs would need to be done for each clinically significant change, increasing patient ($180,000) and hospital ($39,600) costs. CONCLUSIONS: Helical TCT is a highly sensitive imaging modality for the thoracic cavity; however, routine CXR still provides clinically valuable information for the initial trauma evaluation at minimal cost. TCT should be reserved for selected cases and not as a primary imaging tool.

Accidents, Traffic↗
PubMed2000

[Treatment of diaphragmatic ruptures by laparoscopic approach in the lateral position].

STUDY AIM: The aim of this retrospective study was to assess the feasibility of the treatment of recent diaphragmatic ruptures through laparoscopic approach in lateral position in patients with stable hemodynamic condition. PATIENTS AND METHOD: From 1994 to 1999, seven patients, 16 to 68 years old, were operated on for diaphragmatic rupture after a 6 hours to 15 days delay. Diaphragmatic rupture was located on the left side in 6 patients, on the right side in 1. Diagnosis was confirmed by CT-scan with reconstructions; there was no associated visceral injury. Patients were operated on by laparoscopic approach in lateral position, herniated viscera reintegrated by moderate pulling and diaphragmatic rupture repaired with non resorbable continuous suture. RESULTS: Stomach was the usual herniated viscera (n = 6); hemothorax was less than 300 cL; diaphragmatic rupture was 8 to 12 cm long. Duration of surgery was no more than 120 minutes. The seven patients after a two months to two years delay had normal chest X-rays. CONCLUSION: The laparoscopic approach in lateral position provides good visibility of the diaphragmatic lesions, easy reduction of herniated organs, complete thorax exploration and cleaning, and easy diaphragmatic repair. This technique is only feasible in patients with stable hemodynamic conditions and does not provide a complete abdominal exploration.

Adolescent↗
PubMed1999

[Pulmonary aspergilloma: results of surgical treatment. Report of a series of 206 cases].

STUDY AIM: The aim of this retrospective study was to report the results of the surgical treatment in 188 patients operated on for pulmonary aspergilloma in a series of 206 patients observed in Morocco. PATIENTS AND METHOD: From 1982 to 1998, 206 patients were treated for pulmonary aspergilloma in the same hospital; 188 were operated on and surgery was contraindicated in the other patients with general or respiratory failure. Hemoptysis was the main symptom, present in 190 patients (92%). Surgery was performed on principle with 108 lobectomies, 38 segmentectomies, 18 lobectomies and segmentectomies, 21 pleuropneumonectomies and 3 thoracoplasties. RESULTS: Postoperative complications occurred in 36% of the patients including: pyothorax (n = 15), hemothorax (n = 10), rehabitation defects (n = 17) and respiratory failure (n = 10). Reoperation was necessary in 6 patients. Postoperative mortality rate was 6.4% (12 patients including 5 treated by pleuro-pneumonectomy). CONCLUSION: The surgical treatment, in spite of its high morbidity, has to be proposed to all patients with pulmonary aspergilloma, even in asymptomatic patients when there is no surgical contraindication. Pleuropneumonectomy is a very high risk procedure and its indications must be restricted. Thoracoscopy was rarely performed in this series.

Adolescent↗
PubMed1995

Penetrating trauma and emergency surgery in patients with AIDS.

BACKGROUND: Several recent publications have suggested that emergency surgery in patients with acquired immunodeficiency syndrome (AIDS) is associated with extremely high morbidity and mortality. PATIENTS AND METHODS: We reviewed the records of 21 patients with AIDS at the University of Miami/Jackson Memorial Medical Center in Miami, Florida, who underwent 24 emergency operations after sustaining penetrating trauma RESULTS: Nineteen patients (90%) presented with gunshot wounds and 2 (10%) presented with stab wounds. Two patients underwent multiple surgical procedures to control hemorrhage from a complex liver injury and to drain a retained hemothorax, respectively. After surgery, patients were managed according to standard protocols, the same as those for non-AIDS patients. Wound infection was present in 4 patients (19%), and occurred only in patients with < 100 CD4+ cells/microL. Fifty-seven percent of patients had no prior knowledge of having AIDS or being seropositive for the human immunodeficiency virus. One patient died after surgery and 18 patients (86%) were still alive 6 months after discharge. CONCLUSIONS: As the AIDS epidemic grows, general surgeons will be treating an increasing number of these patients. A low morbidity and mortality can be obtained with standard surgical care and techniques. Complications are not uncommon and should be treated as in any other surgical patient, unless it is a terminal condition or that posture runs against the patient's stated views or advance directives.

Acquired Immunodeficiency Syndrome↗
PubMed2003

[Videothoracospy in thoracic trauma and penetrating injuries].

Videothoracoscopy represents a valid and useful approach in some patients with blunt chest trauma or penetrating thoracic injury. This technique has been validated for the treatment of clotted hemothorax or posttraumatic empyema, traumatic chylothorax, traumatic pneumothorax, in patients with hemodynamic stability. Moreover, it is probably the most reliable technique for the diagnosis of diaphragmatic injury. It is also useful for the extraction of intrathoracic projectiles and foreign bodies. This technique might be useful in hemodynamically stable patients with continued bleeding or for the exploration of patients with penetrating injury in the cardiac area, although straightforward data are lacking to confirm those indications. Thoracotomy or median sternotomy remain indicated in patients with hemodynamic instability or those that cannot tolerate lateral decubitus position or one-lung ventilation. Performing video-surgery in the trauma setting require expertise in both video-assisted thoracic surgery and chest trauma management. The contra-indications to videothoracoscopy and indications for converting the procedure to an open thoracotomy should be perfectly known by surgeons performing video-assisted thoracic surgery in the trauma setting. Conversion to thoracotomy or median sternotomy should be performed without delay whenever needed to avoid blood loss and achieve an adequate procedure.

Hemodynamics↗
PubMed2000

Spontaneous rupture of the thoracic aorta.

BACKGROUND: Spontaneous rupture of the thoracic aorta without trauma, aneurysm, or dissection is an extremely rare but catastrophic disorder. Two cases of spontaneous aortic rupture are presented, both treated surgically with satisfactory results. METHODS: A review of the English literature found 16 patients with the diagnosis of spontaneous rupture of the thoracic aorta from 1961 through 1998. Eighteen reported cases, including the 2 cases presented herein, are reviewed. RESULTS: The representative clinical picture is one of a middle-aged hypertensive patient with acute chest pain and collapse, with imaging modalities demonstrating hemopericardium, hemomediastinum, or hemothorax. According to the reported experiences, aortography was accurate for identifying the rupture site although the findings were sometimes subtle. Misdiagnosis or nonsurgical management resulted in the patient's death. All 8 patients who did not undergo aortic repair died within 3 weeks after the onset, whereas 9 of 10 patients who underwent surgical aortic repair survived. CONCLUSIONS: For patients with a definitive or possible diagnosis of spontaneous rupture of the thoracic aorta, prompt operation is imperative through an optimal surgical approach to identify and repair the rupture site with appropriate circulatory support.

Aged↗
PubMed2001

Surgical treatment of active and sequelar forms of pulmonary tuberculosis.

BACKGROUND: The incidence of tuberculosis has risen since 1990, and in some countries, the resistant forms are becoming more and more frequent. Surgical treatment is once again needed to manage these problems. The purpose of this study was to analyze the indications and results of resection, which we performed for pulmonary tuberculosis. METHODS: From 1980 to 1997, 477 patients were operated on for thoracic or intrathoracic tuberculosis in Laennec Hospital, Paris (259 suffered lung diseases). There were 165 women and 94 men, aged 25 to 86 years (mean 46 years), from Europe (n = 148), North Africa (n = 65), Subsaharian Africa (n = 34), Asia (n = 7), and the West Indies (n = 5). This population was reviewed concerning the lung tuberculosis (sequelae or active lesions), the indications of lung resection, the type of resections performed, and the results at 1, 6, and 12 months. RESULTS: Active lesions were present in 97 cases and sequelae in 162. Surgery was performed for a therapeutic purpose in 104 patients with sequelae, and in 10 patients with active tuberculosis (pneumonectomy, n = 19; pleuropneumonectomy, n = 19; lobectomy, n = 54; and segmentectomy, n = 22). Surgery was performed for a diagnostic purpose in 54 patients with sequelae, and in 87 patients with active lesions (lobectomy, n = 32; segmentectomy, n = 19; wedge resection, n = 94, of which 11 performed by video-assisted thoracoscopy since 1991). One patient died after pleuropneumonectomy. We observed 25 complications: empyema, n = 7; hemothorax, n = 2; prolonged air leaks, n = 14; and pneumopathy, n = 2. All patients with active lesions subsequently were given antitubercular drugs. Follow-up was 100% at 1 month, 57% (n = 92) and 77% (n = 75) at 6 months for patients with sequelae and for patients with active lesions, respectively. All were asymptomatic with a normal chest roentgenogram. The number of operations for active lesions is increasing over the years, while it is decreasing for sequelar lesions. CONCLUSIONS: In our department, surgery is being performed more frequently to make a diagnosis in cases of active tuberculosis, and to treat complicated lesions in case of sequelae. Lung resection for active tuberculosis evolving under treatment or for drug resistance was rare. However, our study confirms the good results commonly obtained by surgery and supports the idea that surgery may help eradicate tuberculosis when social and economic circumstances render its medical management difficult or hazardous.

Adult↗
PubMed2001

Modifications in surgical implantation of the Penn State electric total artificial heart.

BACKGROUND: Two modifications of the surgical implantation protocol for the Penn State Total Artificial Heart (ETAH) were evaluated: Phrenic nerve ischemia was prevented by minimizing dissection and traction; and hemostasis was augmented and ETAH cuff anastomoses reinforced by using fibrin glue. METHODS: Thirteen Holstein calves underwent orthotopic surgical implantation of the Penn State ETAH between February 1998 and August 2000. Mean hemodynamic and laboratory chemistry variables from the first postoperative week were compared between calves receiving the original (n = 7) and modified (n = 6) protocol. RESULTS: Calves assigned to the modified protocol displayed an improvement in the Po2/FiO2 ratio compared to original (419.4 +/- 17.5 vs 336.3 +/- 35.4, respectively; p = 0.05). All additional parameters were equivalent between groups. The percent survival of animals receiving the modified protocol at 2, 4, and 12 weeks was higher than that of animals that underwent the original protocol. Original-protocol calf deaths consisting of hemothorax (n = 3), and respiratory failure (n = 1) were prevented in the modified protocol. CONCLUSIONS: Our results suggest that manipulations in surgical protocol may promote increased survival in calves implanted with the Penn State ETAH.

Animals↗
PubMed2001

Video-assisted thoracoscopic "resympathicotomy" for palmar hyperhidrosis: analysis of 42 cases.

BACKGROUND: There are rare reports of video-assisted thoracoscopic resympathicotomy for patients with palmar hyperhidrosis. I present our experience in treating a persistent or recurrent palmar hyperhidrosis after primary endoscopic sympathectomy or sympathicotomy and discuss the perioperative management. METHODS: We reoperated on 42 patients using a technique of video-assisted thoracoscopic resympathicotomy. All patients were placed in a semi-sitting position under single- or double-lumen intubated anesthesia. An 8-mm, 0 degrees thoracoscope was used to interrupt the nerve conduction to the palms from the T2 and T3 ganglia, through one or two 0.8-cm subaxillary incisions. RESULTS: The reasons for failure of endoscopic sympathectomy or sympathicotomy in 26 patients included pleural adhesion (15 of 26, 57.7%), incorrect identification of T2 ganglion (3 of 26, 11.5%), vessel overriding or close to sympathetic nerve (3 of 26, 11.5%), incomplete interruption of sympathetic nerve (2 of 26, 7.7%), medially located sympathetic nerve (2 of 26, 7.7%), and aberrant venous arch (1 of 26, 3.8%). The causes of recurrent palmar hyperhidrosis after primary transthoracic endoscopic sympathicotomy or sympathectomy (TES) in 16 patients included a possible effect of T3 ganglion (8 of 16, 50%), Kuntz fiber (3 of 16, 18.8%), nerve regeneration (3 of 16, 18.8%), and incomplete interruption of T2 ganglion (2 of 16, 12.5%). Surgical complications included pneumothorax (1 patient, 2.4%), hemothorax (1 patient, 2.4%), and compensatory sweating (36 patients, 86%). All patients had obtained successful bilateral sympathectomies and had satisfactory results after a mean of 32.1 months of follow-up. CONCLUSIONS: Video-assisted thoracoscopic resympathicotomy is an effective and safe method for a previously unsuccessful sympathectomy or recurrent palmar hyperhidrosis if the surgeon acknowledges possible anatomic variations and can overcome the problems related to pleural adhesions.

Adolescent↗
PubMed2001

Safety and efficacy of intraarterial thrombolysis for perioperative stroke after cardiac operation.

BACKGROUND: Acute ischemic stroke after cardiac operations is a devastating complication with limited therapeutic options. As clinical trials of thrombolysis for acute ischemic stroke exclude patients with recent major surgery, the safety of intraarterial thrombolysis in this setting is unknown. METHODS: Thirteen patients with acute ischemic stroke within 12 days of cardiac operation underwent intraarterial thrombolysis within 6 hours of stroke symptom onset. The National Institutes of Health Stroke Scale was used to assess neurologic recovery. RESULTS: The mean age was 69 years (standard deviation +/-5 years) and 62% were men. Cardiac procedures included valve operations in 6 patients, coronary artery bypass grafting in 4, valve and coronary artery bypass grafting in 2, and left ventricular assist device in 1 patient. Atrial fibrillation occurred in 5 patients (38%). The mean time from operation to stroke was 4.3 days (standard deviation +/- 3 days). Thrombolysis was initiated within 3.6 hours (standard deviation +/-1.6 hours) of stroke symptom onset. Recanalization was complete in 1 patient, partial in 5, and 7 patients had low flow. Neurologic improvement occurred in 5 patients (38%). One patient needed a chest tube for hemothorax, 2 others were transfused for low hemoglobin. No operative intervention for bleeding was necessary. CONCLUSIONS: In select patients with acute ischemic stroke after recent cardiac operation, intraarterial thrombolysis appears to be reasonably safe and may lead to neurologic recovery.

Aged↗
PubMed2001

Management of catheter-induced pulmonary artery perforation: a rare complication in cardiovascular operations.

BACKGROUND: Pulmonary artery perforation is a rare but often fatal complication of the pulmonary artery catheter occurring in cardiovascular operations and at catheterization facilities. We used our experience and a review of the literature to formulate diagnostic and management strategies. METHODS: During a 13-year period, 12 patients with pulmonary artery perforations were treated in a center that performed an average of 860 open-heart procedures per year. Clinical presentation varied from minor hemoptysis to major airway hemorrhage, hypoxia, exsanguination, and cardiac arrest. Airway bleeding occurred shortly after weaning from cardiopulmonary bypass in 5 patients or postoperatively after wedging the catheter in 6. One patient developed a hemothorax and had a cardiac arrest. Treatment included assurance of gas exchange, endobronchial lavage, isolation of the bleeding bronchus and control of hemorrhage by conservative therapy, pulmonary resection, pulmonary artery repair, and arterial embolization. RESULTS: Five of the 12 patients died (42%). Recurrent hemorrhage occurred in 40% of patients (2 of 5) treated conservatively compared with none of the patients (0 of 7) having surgical treatment. Forty three percent of patients (3 of 7) treated surgically died; 20% of patients (1 of 5) treated conservatively died. One patient succumbed without treatment. CONCLUSIONS: Pulmonary artery perforation is a rare and often fatal complication of pulmonary artery catheterization. This was apparent with patients who had airway hemorrhages as a result of weaning from cardiopulmonary bypass or after balloon inflation. Recurrent and fatal hemorrhage was frequent in patients treated by conservative therapy alone. Surgical intervention was effective in control of hemorrhage but did not reduce the number of deaths. Treatment remains highly individualized. It is advisable to be cautious in inserting Swan-Ganz catheters and to avoid their use unless absolutely necessary.

Aged↗
PubMed2002

Seat belt-related chondrosternal disruption with lung herniation.

A case of blunt chest trauma resulting in anterior chondrosternal separation with right lung herniation and hemothorax is presented. The injury is related to the use of a seat belt restraint. The patient underwent surgical repair with polytetrafluoroethylene chest wall reconstruction. Postoperative recovery was complicated by respiratory insufficiency due to underlying pulmonary contusion and multiple rib fractures.

Cartilage↗
PubMed2003

Minimally invasive surgery in the treatment of empyema: intraoperative decision making.

BACKGROUND: Pneumonia, parapneumonic effusions, and empyema continue to be significant health problems, especially in elderly individuals. Minimally invasive thoracic surgery in the treatment of empyema has been demonstrated but has not been well defined. Furthermore, it has not been determined how to choose patients who can be treated with thoracoscopy versus thoracotomy. We report the results of a strategy in which all patients were initially approached with thoracoscopy and converted to open decortication only if the lung could not be inflated to fill the chest. METHODS: A total of 172 patients underwent decortication for empyema over a 5-year period. Thoracoscopic decortication was attempted in all patients; patients were converted to open decortication if access to the pleural space was not possible, or if the lung could not be mobilized sufficiently to reach both the chest wall and the diaphragm. Proportions were compared using the chi(2) test. RESULTS: Of the 172 patients, 66 successfully underwent decortication with thoracoscopic techniques only. The remaining 106 patients required complete thoracotomy. No difference was found in the reoperation rate; 3 of 106 open thoracotomy patients underwent reexploration for recurrent empyema, whereas two of 66 thoracoscopy patients required reoperation for hemothorax (p = 0.347). There was a tendency for thoracoscopic patients to require reoperation for bleeding (p = 0.08); both patients taken back to the operation room for bleeding had undergone thoracoscopic pleurectomy. Eleven of 166 patients (all explored with open thoracotomy) died after decortication, for a mortality rate of 6.6%. All of these patients had gone to surgery from the intensive care unit. CONCLUSIONS: Using the criteria of complete expansion of the lung surface to the chest wall and diaphragm allowed accurate selection of patients who could undergo complete thoracoscopic decortication without risk of recurrent empyema. Computed tomographic scans did not help to predict which patients would require open procedures. Thoracoscopic patients were more likely to require reoperation for bleeding if thoracoscopic pleurectomy was performed.

Adolescent↗
PubMed2003

Twenty-six years of experience with the modified eloesser flap.

BACKGROUND: Empyema thoracis is a common thoracic problem with a multitude of therapeutic options. The modified Eloesser flap (MEF) is one means of dealing with this problem in selected complicated patients. The purpose of this study is to report our 26-year experience with the MEF. METHODS: A review of 78 patients who had a MEF from 1975 to 2001 was performed. RESULTS: There were 52 males (67%) and 26 females (33%). Mean age was 59 +/- 14 years. The overall length of stay was 26 +/- 27 days, while mean postoperative length of stay was 16 +/- 17 days. Microbiology of the empyema cavity revealed a predominance of gram-positive organisms. Before a modified Eloesser flap, all patients failed initial conservative interventions and 23 patients (29%) failed surgical interventions. Operative indications were as follows: parapneumonic effusions, 35 patients (45%); postresectional, 23 patients (29%); tuberculosis related, 7 patients (9%); malignant effusion, 4 patients (5%); esophageal fistulas, 4 patients (5%); abdominal sepsis, 3 patients (4%); and hemothorax secondary to trauma, 2 patients (3%). The inverted-U incision was performed in all patients. Average rib resection was 3 +/- 1 ribs. There were no intraoperative complications and adequate drainage was achieved in all patients. Thirty-day morbidity/mortality was 4 patients (5%): 3 died of sepsis and 1 died of metabolic encephalopathy; although long-term follow-up (mean: 109 +/- 141 months) revealed no additional morbidity related to the MEF. CONCLUSIONS: We demonstrate that MEF can be performed as a safe, definitive surgical procedure for the treatment of chronic empyema thoracis. The MEF remains an important option in the surgical treatment of chronic, complicated empyema thoracis.

Adult↗