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PubMedDate not supplied

Chylothorax: report of a case complicating orthotopic heart transplantation.

We describe a case of a chylothorax that occurred in a 62-year-old man after orthotopic heart transplantation. Injury to collateral lymphatics in the anterior mediastinal or thymic areas was the probable cause of the chylous fistula. Excessive chyle drainage causes loss of large amounts of fat, protein, electrolytes, and lymphocytes. These losses further compromise the nutritional and immunologic status of the transplant patient. Conservative therapy with chest tube drainage and a strict medium-chain triglyceride diet allowed the chylous fistula to spontaneously close without the need for surgical intervention.

Chest Tubes↗
PubMed2003

Re-expansion pulmonary oedema and circulatory shock in a 20-year-old man.

Re-expansion pulmonary oedema is a well-recognized rare complication of the treatment of spontaneous pneumothorax. It has been associated with death in 20% of cases. A fit 20-year-old man who had returned from holiday 2 days previously presented with a large left-sided pneumothorax of 10 days' duration. He had exhibited symptoms of chest pain and shortness of breath during the return flight. He showed no signs of respiratory distress at presentation to the Accident and Emergency Department, but after treatment with a chest tube in the ensuing 90 min developed severe unilateral re-expansion pulmonary oedema and circulatory collapse. Factors in the aetiology of the condition and prevention are considered.

Adult↗
PubMed2001

The bilobectomies for lung cancer.

BACKGROUND: The purpose of our retrospective study is to confirm that bilobectomy is a feasible operation with an oncological value. METHODS: From 1981 to 1998, 46 patients underwent bilobectomy for lung cancer. Eight upper and middle lobectomies (UML) and 38 middle and lower lobectomies (MLL) were performed. Intraoperative pneumoperitoneum was done in 11 MLL. We have considered operative mortality, postoperative complications, the persistence of drainage tubes and the length of hospital stay and the data were statistically compared with those relative to right lobectomies. Survival was estimated with the Kaplan-Meier method and the curves were compared with those of the right lobectomies and right pneumonectomies using the log-rank test. RESULTS: Overall morbidity was 43.4%. Mortality was 6.5%. Mean chest tube persistence was 7.8 days and mean hospital stay was 14 days. No statistical significance was found about these data comparing the UML and MLL separately and the bilobectomies with the right lobectomies. The pneumoperitoneum done in the MLL enabled a shorter hospital stay, statistically significant, in comparison with MLL without pneumoperitoneum. The overall 5-year survival rate was 38%. Considering the I and the II stages no statistical differences in survival were found considering the right lobectomies and right pneumonectomies. CONCLUSIONS: The bilobectomies can have a role in treatment of lung cancer that is equal to the other standard major resections.

Adult↗
PubMed1994

[Thoracic drainage tubes].

The invasive procedures handled by the pulmonologist in the diagnosis of lung disease have greatly expanded over the last decade (transbronchial, percutaneous or thoracoscopic pulmonary biopsy and needle aspiration). The growing number of intensive care units with facilities in mechanical ventilation and hemodynamic support has also modified the approach of the critically ill patient. Pneumothorax and hemothorax are well-known complications related to these diagnostic and therapeutic techniques. Other areas of interest and up-to-date are diagnostic thoracoscopy in pleural disease, chemical pleurodesis in patients with pneumothorax or malignant pleural effusion, and the administration of intrapleural fibrinolytics in the treatment of empyema. This evolution implicates that the pulmonologist and the intensivist be skilled in the management of chest tubes. In this article we review the indications, some technical topics and the principal complications related to the placement of thoracic drains.

Chest Tubes↗
PubMedDate not supplied

Thoracoscopic decortication: first-line therapy for pediatric empyema.

Video-assisted thoracoscopic surgery (VATS) has become a popular and well-refined procedure. It has several advantages over open thoracotomy in terms of invasiveness and cosmetics. The aim of this study is to consider if VATS can serve as primary management for pediatric empyema. Between October 2000 and December 2002, 13 children with empyema receiving VATS were retrospectively reviewed. Of them, 5 had tube thoracostomy before VATS intervention (group T), and 8 had VATS as the initial treatment (group V). Their mean (+/- SD) age of groups V and T were 5.75 +/- 4.43 and 4.0 +/- 1.58 years, respectively. The children of group V had a shorter length of hospital stay (group V 10.7 +/- 3.54 days; group T 28.2 +/- 8.32 days), a shorter period of chest tube drainage (group V 5 +/- 1.87 days; group T 25 +/- 11.08 days), less transfusion (group V 0.4 +/- 0.17 units; group T 0.9 +/- 0.27 units) and less radiation exposure (group V 10.3 +/- 3.49; group T 23.4 +/- 11.64). No mortality was noted in the entire series. We conclude that primary VATS is a safe, effective and definitive method which can serve as first-line therapy for children with empyema.

Adolescent↗
PubMed2006

Physicians assistants in cardiothoracic surgery: a 30-year experience in a university center.

BACKGROUND: The purpose of this study was to evaluate our 30 years of experience with the use of physician assistants (PAs) on a cardiothoracic surgery (CTS) service. METHODS: A retrospective review of the utilization of CTS PAs was performed at a university center from 1973 to 2003. RESULTS: The number of PAs has increased from 2 (1973) to 23 (2003), corresponding to the increased clinical service demands with a constant resident number for the past decade. Physician assistant employment has expanded from one hospital to five hospitals in our university system where CTS is performed. The CTS service has expanded from 400 total cases per year (1973) to 4,000 cases (2002). We have had a 50% retention rate with duration of employment from 6 months to 28 years (11 PAs with service more than than 15 years). The PA role has changed little, with duties varying from history and physical examination, conduit harvesting, insertion of invasive catheters and chest tubes, surgical first assisting, closure of the chest, and optional primary intensive care unit night-time in-house call. Salary currently ranges from 55,000 dollars to 100,000 dollars depending on length of service and overall merit. Job satisfaction for PAs employed longer than 12 months has remained high. CONCLUSIONS: The addition of PAs to our CTS university service has allowed us to resolve many problems of work assignment and coverage and enabled us to establish effective and efficient surgical teams without increasing the number of categorical CTS residents.

Forecasting↗
PubMed1977

[Open combined thoracic and abdominal wounds (author's transl)].

We report 27 open wounds of the thorax and abdomen combined, which were treated during one year on the hospitalship "Helgoland" in Vietnam. The patients came from every age group. 12 of the wounded were male, 15 were female. Hemopneumothorax was the most frequent finding in the thoracic wounds. With abdominal wounds the organs of the upper abdomen were mainly involved. We found it best to begin treatment with closed chest-tube drainage in order to bring the chest wound under control, then to proceed with laparatomy. Only in a few cases was a thoracotomy necessary. 4 of the 27 wounded died.

Abdominal Injuries↗
PubMed1989

[Results and complications of treatment of acute and chronic pleural empyema--a retrospective analysis of the last 5 years].

In 162 patients treated surgically for pleural empyema, 212 surgical interventions were necessary. As primary treatment cest-tube drainage was more effective than closed chest tubes. Decortication, which was carried out in 43 patients, was followed by further surgical procedures in three patients. If primary treatment is not effective early decortication is indicated to avoid septic complications (30-day mortality amounted to 7.4%). Two patients died from septic complications.

Chronic Disease↗
PubMed1981

Herniation of the heart following left pneumonectomy.

After left pneumonectomy cardiac herniation occurred and caused a new radiologic finding, "the displaced chest tube." Diagnostic pneumothorax was helpful. The emergency chest radiograph enables rapid diagnosis of this life-threatening condition.

Aged↗
PubMed1995

Outpatient thoracoscopy: a case report and discussion.

Thoracoscopy has long been recognized as having significant diagnostic and therapeutic value. We present a new, less invasive method of obtaining good biopsy specimens of pleural based lesions using a single incision and on an outpatient basis. JW, who has a history of Hodgkin's Lymphoma, presents with a suspicious pleural mass adjacent to the AP window and not amenable to percutaneous biopsy. She was admitted to the ambulatory surgery unit and underwent video thoracoscopic biopsy of the lesion through a single 12 mm incision. Surgery time was 25 minutes, and frozen section revealed Hodgkin's lymphoma. No chest tube was inserted, and post-op chest film revealed a small pneumothorax that resolved in 4 hours. The patient was ready for discharge at that time. The technique we used involved placing a standard 10 mm trocar and scope in the midaxillary line with the patient in the lateral decubitus position. Once the scope is in, the trocar is pulled back so that a mediastinal biopsy forcep can be placed alongside the camera through the same hole. The biopsy is taken, and irrigation and cautery instruments can then also be placed and used in a similar manner. Before removing the camera, a prolene pursestring suture is placed around the incision. While the anesthesiologist inflates the lung, the camera is slowly removed, watching all lobes inflate. The pursestring is then tied and the patient awakened. We have performed seven of the above procedures thus far with good results. We feel the following are essential in patient selection for outpatient thoracoscopy: 1) The lesion to be biopsied is pleural based.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1998

Competency-based instruction in critical invasive skills improves both resident performance and patient safety.

BACKGROUND: Correct performance of invasive skills is essential, but residents often undertake such procedures after no or minimal instruction. METHODS: We instructed eight postgraduate year 1 (PGY1) residents in the cadaver laboratory using a competency-based approach (CBI). Each resident had been evaluated before the laboratory during patient encounters. Group instruction in endotracheal tube insertion (ET), venous cutdown (VC), and chest tube insertion (CT) was followed by individual pretesting and hands-on teaching, with 100% competency the goal. Failure was considered an inability to perform the task correctly or within 120 seconds. After the laboratory, residents were evaluated for correctness and rapidity of performance. RESULTS: Prelaboratory failures consisted of ET, 7; CT, 5; VC, 7. Postlaboratory failures were 0 for all. Prelaboratory complications consisted of ET, 3.3 +/- 1.1; CT, 1.9 +/- 1.0; VC, 3 +/- 1.0. Postlaboratory complications were 0 for all. Prelaboratory times (seconds) were ET, 66.5 +/- 30.8; CT, 104 +/- 4.1; VC, 116.3 +/- 0.7. Postlaboratory times were ET, 25 +/- 7; CT, 65.5 +/- 10.7; VC, 81.3 +/- 2.5. Changes were statistically significant for all (P < .03, nonparametric). Residents performed 20 CTs with 1 pneumothorax, 80 ETs with 2 failures, and 20 VCs with no complications. Initial trauma resuscitation time decreased from 25 to 10 minutes. CONCLUSIONS: (1) Residents' skills rapidly improve with CBI; (2) skills learned through CBI in the laboratory can be translated to and sustained in the clinical setting; (3) CBI produces competent residents who perform skills rapidly and with minimal complications.

Cadaver↗
PubMed2006

Malignant pleural effusion treatment outcomes: pleurodesis via video-assisted thoracic surgery (VATS) versus tube thoracostomy.

STUDY OBJECTIVES: Video-assisted thoracic surgery (VATS) has been widely used in the diagnosis and management of various thoracic diseases. The objective of this retrospective study was to compare the effectiveness of patients undergoing pleurodesis through VATS versus tube thoracostomy for malignant pleural effusion (MPE). Study design was a retrospective review of patients treated in medical centers and hospitals in Taiwan. PATIENTS: One hundred and forty-eight patients with MPE resistant to systemic therapy resulting from various types of carcinomas were retrospectively reviewed. VATS pleurodesis was carried out in 82 and tube thoracostomy with pleurodesis in 66 patients. RESULTS: There were no intraoperative deaths and 4 (2.7 %) in-hospital deaths. One hundred and eighteen (79.7 %) patients were available for follow-up. There were no statistically significant differences in the preoperative characteristics of the two treatment groups, except that the amount of effusion and the percentage of patients with dyspnea were both higher in the VATS treatment group. The duration of chest tube drainage was significantly longer ( P < 0.01) in the tube thoracostomy treatment group (9.1 +/- 3.3 vs. 6.2 +/- 2.3 days). There were no significant differences between the treatment groups with regard to the incidence of surgical complications and perioperative mortality. Median survival was similar in both treatment groups; however, the VATS treatment group had a significantly longer median recurrence-free survival than the tube thoracostomy treatment group. CONCLUSIONS: VATS treatment for MPE appears to be superior to tube thoracostomy for diagnostic accuracy and effectiveness in preventing effusion recurrence; however, the role of these treatments for MPE is palliative, and does not significantly prolong survival time.

Adult↗
PubMed1996

Massive chylothorax complicating cirrhosis of the liver.

Chylothorax is an unusual complication of cirrhosis of the liver. This condition is probably underdiagnosed because appropriate tests are not usually done. We describe the case of a 54-year-old man with cirrhosis of the liver and massive chylothorax. Despite chest tube drainage and intensive supportive therapy, there was a fatal outcome. Our case highlights the difficulties in the management of this complication and draws attention to the possible dangers of certain therapeutic procedures.

Chest Tubes↗
PubMed1996

Intermediate results of the extracardiac Fontan procedure.

BACKGROUND: Fourteen children (ages 2 to 14 years) and 1 adult (32 years) have undergone a modification of the Fontan procedure in which an extracardiac lateral tunnel or conduit is used in combination with staged or simultaneous bidirectional Glenn shunt(s). METHODS: Extracardiac lateral tunnels (n = 9) were constructed using a polytetrafluoroethylene patch (n = 7), pericardial patch (n = 1), or in situ pericardial flap (n = 1). Extracardiac lateral conduits (n = 6) were constructed using nonvalved homografts (n = 2) or polytetrafluoroethylene tube grafts (n = 4). Fenestrations were created in 4 patients (2 each in extracardiac lateral tunnel and extracardiac lateral conduit patients). Aortic cross-clamping was completely avoided in 12/15 patients (aortic cross-clamping in 2 patients for atrial septal defect enlargement and 1 for Damus-Kaye-Stansel procedure). RESULTS: There have been no operative deaths. Prolonged postoperative chest tube drainage (> 2 weeks) has been rare (n = 1). At follow-up (range, 6 to 54 months; mean, 27.5 months), all patients are in New York Heart Association class I or II and remain in normal sinus rhythm. Late protein-losing enteropathy was seen in 1 patient and was successfully treated by percutaneous creation of a stented fenestration from the extracardiac tunnel to the systemic atrium. Late catheterizations reveal unobstructed extracardiac lateral tunnel function and low pulmonary pressures (range, 11 to 13 mm Hg). Advantages of the extracardiac Fontan include (1) avoidance of aortic cross-clamping in most patients, (2) the hemodynamic benefits of total cavopulmonary connection, (3) avoidance of atriotomy and intraatrial suture lines, (4) preservation of sinus rhythm and no arrhythmias at 2 year follow-up, (5) drainage of the coronary sinus to low pressure atrium, (6) allowance for early/late fenestrations, (7) prevention of baffle leaks and intraatrial obstruction, and (8) allowance for growth (tunnel procedures only). CONCLUSIONS: We recommend this extracardiac procedure for all suitable patients undergoing surgical conversion to the Fontan circulation.

Adolescent↗
PubMed2004

Acute disseminated encephalomyelitis following pleural empyema owing to Boerhaave's syndrome.

Acute disseminated encephalomyelitis is reported in a 14-year-old male patient associated with a pleural empyema caused by an esophageal perforation. During the hospital course, the patient experienced an episode of cardiac arrest, raising the question of hypoxic-ischemic cerebral injury, but the magnetic resonance imaging (MRI) findings and clinical course were most consistent with acute disseminated encephalomyelitis. After a course of methylprednisolone, broad-spectrum antibiotics, and bilateral chest tube placement, the patient recovered with only mild residual deficits, along with resolution of his MRI findings.

Adolescent↗
PubMed2002

Left pleural effusion after coronary artery bypass decreases with a supplemental pleural drain.

BACKGROUND: This prospective study was undertaken to determine the incidence of symptomatic left pleural effusion after coronary artery bypass grafting, and to determine if routine drainage of the pleural cavity with a supplemental flexible drain reduces this incidence. METHODS: The clinical course of study patients was prospectively recorded during the initial hospitalization and at 6-weeks after surgery. All patients had a mediastinal and a left pleural tube, which were removed on the 1st postoperative day. The supplemental drain system was implanted in a subset of patients and remained in place for 3 to 5 days. A symptomatic effusion was defined as one that required thoracentesis, tube thoracostomy, or readmission for treatment. RESULTS: A total of 460 patients were studied, of whom 115 had a supplemental drain. The two groups (supplemental drain versus control) were equivalent with respect to age, gender distribution, and comorbid diseases. The incidence of symptomatic left pleural effusion for the entire group was 9.8% (45 of 460). Symptomatic left pleural effusion occurred in 11.9% (41 of 345) patients when only chest tubes were used, and in 3.5% (4 of 115) when a supplemental drain was placed. This difference was significant (F ratio 7.583, p < 0.005). There were no complications from the supplemental drain. CONCLUSIONS: The incidence of symptomatic left pleural effusion can be greatly reduced with the use of a supplemental pleural drain that remains in place for several days after surgery.

Aged↗
PubMed2001

Supracostal approach in percutaneous nephrolithotomy: experience with 102 cases.

PURPOSE: To assess retrospectively the safety and efficacy of the supracostal approach in percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS: Among 862 patients who underwent PCNL between April 1986 and December 1999, supracostal puncture was performed in 102. Their stones were either solitary (66.5%), multiple (15.7%), or staghorn (19.6%). Upper ureteral calculi were the commonest indication (32.4%). The interspace between the 11th and 12th ribs was used in all cases. After tract dilatation with telescopic metal dilators, pneumatic or ultrasound lithotripsy was used for fragmentation. RESULTS: Complete clearance was achieved in 79.5%. Ten patients (9.8%) had pleural violation in the form of hydrothorax, pneumothorax, or hydropneumothorax. All of these patients were managed successfully by intercostal chest tube drainage. CONCLUSION: Supracostal puncture in a safe and effective approach with acceptable morbidity in selected cases of staghorn, upper ureteral, and upper caliceal calculi.

Adult↗
PubMed1994

Chylothorax after endoscopic sympathectomy: case report.

Endoscopic sympathectomy is a new trend for the treatment of hyperhidrosis palmaris. It is a simple and effective technique; however, it carries some recognized risks such as Horner's syndrome and pneumohemothorax. We recently encountered a case complicated by the development of a chylothorax. The patient was a 23-year-old healthy women with profuse palmar sweating. She developed an intractable dry cough after a transthoracic endoscopic sympathectomy. A chest x-ray revealed a left pleural effusion. A chylous effusion was found after thoracentesis and fluid analysis. The pleural effusion resolved after chest tube drainage and diet control. Although endoscopic sympathectomy is a simple and quick procedure, unusual complications, such as chylothorax, may occur. Appropriate early recognition and treatment can prevent a disastrous result.

Adult↗