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PubMed1996

The transaxillary approach for treatment of thoracic outlet syndromes.

The diagnosis and management of thoracic outlet syndromes is based on the surgical management of more than 3,000 patients, 800 of which have had recurrent thoracic outlet syndromes. Accurate diagnosis for peripheral nerve compression is based on measurement of the ulnar and median nerve conduction velocities across the thoracic outlet. For sympathetic maintained pain syndrome or causalgia, a stellate ganglion block is helpful. Arteriography and venography are critical to show vascular compression. Conservative management is successful in most cases (70%) initially. For arterial reconstruction, the supraclavicular-infraclavicular approach is recommended. For the Paget-Schroetter syndrome (effort thrombosis of the axillary subclavian vein), prompt thrombolysis followed by transaxillary first rib resection is mandatory. No long-term anticoagulants are necessary. For hyperhidrosis, causalgia, sympathetic maintained pain syndrome or reflex sympathetic dystrophy, transaxillary dorsal sympathectomy with first rib resection or thoracoscopy is the preferred management when conservative therapy fails. For recurrent thoracic outlet syndrome and sympathetic maintained pain syndrome, a high thoracoplasty posterior approach is preferable with neurolysis of the nerve roots and brachial plexus as well as a dorsal sympathectomy. The technique of transaxillary first rib resection with or without dorsal sympathectomy is presented. The use of the thoracoscope expedites the procedure and improves the teaching capability.

Humans↗
PubMed1996

Thoracoscopic management of empyema in children.

The appropriate management of empyema in children is controversial. Traditional surgical approaches have included thoracotomy and open drainage, decortication, and thoracoplasty. While generally effective, these procedures can be associated with considerable morbidity. We have sought to assess the utility of video-assisted thoracoscopic adhesiolysis and pleural debridement for the treatment of empyema in children. Nine children with postpneumonic empyema unsuccessfully managed with a single attempt at closed tube thoracostomy underwent thoracoscopic drainage during the past 2 years. The empyema was successfully treated with this technique in seven patients with no further interventions being required. Procedures performed early in the fibrinopurulent stage were technically easier. The average time before chest tube removal was 8.5 days. An immunocompromised patient required a subsequent open decortication and a patient with a coagulopathy required two subsequent open procedures for drainage of a recurrent hemothorax. We conclude from this experience that video-assisted thoracoscopic adhesiolysis and pleural debridement can be successfully performed in children. Benefits include good visualization of the entire thoracic cavity for more effective debridement and efficient drainage, and subjectively diminished postoperative pain and associated morbidity.

Adolescent↗
PubMed1996

Carinal resection for bronchogenic cancer.

Traditionally, high technical morbidity and mortality and uncertain long-term survival have been associated with carinal surgery for bronchogenic carcinoma. However, growing evidence exists that judicious indications, meticulous surgery, and also perioperative management can decrease surgical mortality. Contraindications include patients whose tumors are so extensive that reconstruction would be under tension and those with involved precarinal and paratracheal nodes. Patients with diseased subcarinal nodes might benefit from surgery. Right carinal pneumonectomy is the most common carinal procedure, and the safe limit of resection is approximately 4 cm between the lower trachea and contralateral main bronchus. Small lesions involving the carina only may be resected without pulmonary resection with somewhat greater resectional limits. Right upper lobe tumors involving the carina may also be completely resected by saving the right middle and lower lobes and fashioning a new carina. Fatal early (noncardiogenic pulmonary edema) and late (anastomotic dehiscence or separation) complications after carinal pneumonectomy may be preventable by limiting mediastinal lymphatic dissection and perioperative intravascular fluid overload. A limited tailored thoracoplasty and transposition of the latissimus and serratus muscles into the postpneumonectomy pleural space can mitigate anastomotic complications. If these recommendations are respected, the technical mortality rates of carinal pneumonectomy can equal those observed after conventional pneumonectomy, and 5-year survival rates in excess of 40% can be expected for NO-1 patients. Invasion of the carina by bronchogenic carcinoma should not be considered by itself a surgical contraindication because the potential for cure is not elusive.

Anesthesia, Inhalation↗
PubMed1977

[Thorax deformity after lung resection during childhood (author's transl)].

Report on a follow-up of 38 children treated with surgery for bronchiectasis during the last 10 years at the Department of Paediatric Surgery at the Dresden Medical Academy. 25 patients could be followed-up. In 17 of them a thoracotomy was performed in an age below 10 years. Besides some minor changes like narrowing of the intercostal spaces several cases with scoliosis of the vertebral column could be found. The importance of early controls and intensive physiotherapy for these cases is stressed. A case with rib osteomyelitis after surgery, which made thoracoplasty necessary is discussed.

Adolescent↗
PubMed1997

[A case of successful operation of tetralogy of Fallot in a 55-year-old man].

A 65-year-old man with Tetralogy of Fallot having respiratory dysfunction is reported. He had a history of pulmonary tuberculosis and experienced right upper lobectomy and thoracoplasty, he had severe hypoxemia (PaO2 35.0 mmHg, Sat, 68.5% under room air) and low quality of life. Total corrective surgery (patch closure for ventricular septal defect, patch enlargement for right ventricular outflow tract, pulmonary valve replacement with bioprosthesis) was performed. Pulmonary edema which was similar to adult respiratory distress syndrome occurred on the first postoperative day after temporary weaning from respirator although circulatory correction was successful. Management with respirator was continued until the 7th postoperative day. It seemed that high pulmonary blood flow and pulmonary hypertension after operation resulted in increase of capillary permeability of lung. One month later there was no gait disturbance and no dyspnea (PaO2 59.8 mmHg, Sat. 92.3% under room air). This patient was the oldest one with Tetralogy of Fallot undergoing successful corrective surgery.

Aged↗
PubMed1997

[Surgical treatment of multidrug resistant pulmonary tuberculosis cases].

UNLABELLED: We report on the results of surgical treatment of pulmonary tuberculosis cases intractable to ordinary therapy due to acquired drug-resistance against multiple anti-tuberculosis drugs (MDR-Tbc). MATERIAL AND METHOD: From 1983 to 1994, 54 patients were administered surgical treatments (60 interventions in all) for pulmonary tuberculosis. Among them, 46 were MDR Tbc cases (52 interventions in all) and were enrolled for this study. The Japanese criteria for drug resistance were referred to, the threshold of resistance in each drug being as follows, INH 0.1, RFP 50, EB 2.5, SM 20, KM 100, TH 25, EVM 100, CPM 100, CS 40, PAS 1 microgram/ml. Bacteriological examinations of sputa were repeated in the postoperative period until upto several years, and the continued absence of Tbc. bacilli for more than 12 months was considered as cured. RESULTS: (1) 37 patients underwent removal of lung mass including tuberculous foci mainly fibrous cavitary lesions (40 interventions in all). The procedures are as follows 22 upper lobectomies and/or partial resections of adjacent lobes. 1 middle lobectomy. A lower lobectomy, 14 pneumonectomies, 2 segmentectomies. In 3 cases, multiple operations were carried out on 2 occasions; 2 upper lobectomies followed by completion pneumonectomies. 1 right upper lobectomy followed by left S3 segmentectomy. Except 2 cases having died of pneumonia and suicide within 12 months after operation, we have 38 cases available for evaluation. Bacteriological relapses were confirmed in 7 among 38 cases postoperatively. 2 of these 7 relapsed cases underwent additional completion pneumonectomies and attained complete cure. Bacteriological relapse-rate was therefore 18.4% (7/38) and the ultimate cure rate of pulmonary MDR-Tbc was 88.6% (31/35). (2) 7 patients underwent thoracoplasties (not corrective, once for each patient). In 2 cases bacteriological relapse was confirmed. Other 5 cases remained bacteriologically silent over a long postoperative period. (3) 4 patients underwent cavernostomies, 3 of them got satisfactory result in reducing the bacterial presence in the sputum (preoperative abundant bacilli (Gaffky 7, 8) turned mean-negative within 2 months after cavernostomy). CONCLUSION: With the above-mentioned results we conclude that surgical treatment is highly effective in intractable pulmonary MDR Tbc cases.

Adult↗
PubMed1997

[Surgical treatment for patients with atypical mycobacteriosis].

We have been conducting surgical therapy for patients with atypical pulmonary mycobacteriosis (AM) since 1965 and have reported on the outcome of this approach to treatment. We have found that chemotherapy is not adequately efficacious against type III Mycobacterium avium complex (MAC), which suggests that surgical intervention may be the optimum approach for MAC. Among MAC patients who were treated surgically at our hospital in the period between 1966 and 1994, 74 cases on whom postoperative follow-up observation was possible served as the subjects of the present investigation. We report here on the outcome of treatment and related problems in these patients. Thirty-nine patients gave positive results for bacterial discharge on smear tests and all were positive on culture. Operation was performed on the right lung in 46 patients and on the left lung in 16. Pneumonectomy was conducted in 10 patients and lobectomy in 20. Other operative modes used included segmental resection in 9, pyothorax in 7, and thoracoplasty in 5 patients. Postoperative bacterial excretion was observed in 15 patients and was persistent bacterial discharge were advanced cases with lesions in another lobe, cases with a past history of tuberculosis, cases of cavitation with lesions on the contralateral side or cases with massive bacterial discharge prior to surgery. Postoperative death occurred in 5 patients: the cause of death was lung cancer in 1 case, serum hepatitis in 1 case, and respiratory failure evidenced by enlarged shadows in 3 cases. These findings pointed to a marked significance of surgical therapy for MAC patients. However, recurrent bacterial discharge has been observed occasionally in some patients even 5 years after surgery. This suggests the need for careful ongoing assessment of the efficacy of surgical therapy and long-term postoperative follow-up.

Adult↗
PubMed1997

[An experience with omentopexy for the repair of postoperative bronchopleural fistula].

Postoperative bronchopleural fistula has been the most troublesome complications in the thoracic surgery. In this report, we presented a case of bronchopleural fistula successfully closed by omentopexy. A 51-year-old man had undergone left upper lobectomy and S6 segmentectomy for primary lung cancer. Bronchopleural fistula due to postoperative pneumonia was developed and completion pneumonectomy with the intercostal-musclo-pexy was performed. Post-re-operative course was unsuccessful, bronchopleural fistula remained, so we tried re-closure of the bronchial stump by omentopexy without thoracoplasty or muscle flap plombage. About a half year after 3rd operation, he relapsed into bronchopleural fistula. Then fibrin gluing was performed via a flexible fiberoptic bronchoscope without hospitalization, and the omental flap was fixed completely to the bronchial stump. We believe the omentopexy a useful procedure for treating postoperative bronchopleural fistula which can't make any chest-wall deformation.

Bronchial Fistula↗
PubMed1997

[Risk of respiratory insufficiency caused by thoracic rigidity].

Three patients, a man aged 71 and two women aged 47 and 54, were admitted for chronic obstructive pulmonary disease and cardiac failure. All three had thoracic deformities, owing to earlier pneumonectomy with thoracoplasty because of pulmonary tuberculosis, congenital kyphoscoliosis, and infant poliomyelitis respectively. Such patients are at risk of developing chronic respiratory insufficiency because of chronic alveolar hypoventilation: muscle power decreasing with age gradually fails to meet the increased respiratory labour. Often, the respiratory insufficiency is not noticed because the problems are ascribed to secondary chronic obstructive pulmonary disease or cardiac failure. The first sign of imminent respiratory insufficiency is nocturnal carbon dioxide accumulation. Therapy consists of respiratory assistance at night by positive air pressure ventilation via a nose mask.

Aged↗
PubMed1990

[Treatment of secondary empyema following lung resection complicated with internal fistula].

To clarify the results of treatment of secondary empyema following lung resection complicated with internal fistula, 81 cases treated at 31 different institutions during the 5 years period from 1983 to 1987 were analysed. 1) All cases of thoracic empyema treated surgically and secondary empyema following lung resection complicated with internal fistula did not decreased during the study period, in spite of the remarkable decrease of surgical cases for pulmonary tuberculosis. 2) The highest rate was observed in males over 50 years of age. 3) Bacteriologically positive case in empyema space was occupied about 70%. 4) 196 operations (including drainage) of 17 types were performed on 81 patients. Only 16% of the cases were successfully treated with one stage of operation. 5) Principal surgical procedure applied in cases under this study was drainage followed by closure of fistula with muscle plombage and with or without thoracoplasty. Case of air plombage and omental pedicle flap plombage have increased recently in Japan. 6) Success rate was 55.6%, failure rate was 32.1% and the mortality was 12.3%. These results indicate the difficulty involved in treatment. Therefore, to avoid occurrence of secondary empyema cases, careful selection of surgical indication, sufficient training in surgical technique and good preoperative and postoperative management are crucial.

Adult↗
PubMed1998

[Approach to bronchopleural fistula in patients undergoing lung cancer surgery. A prospective study].

Twenty-four cases of bronchopleural fistula were found by fiberoptic bronchoscopy performed in 526 consecutive patients undergoing surgery for diagnosis or treatment of lung cancer between February 1990 and January 1997 in Hospital General Universitario in Valencia (Spain). In 327 of the patients lung resection was performed. Clinical symptoms included fever, purulent or bloodstained expectoration, chest pain, dyspnea and general unfitness, with 83.33% of the patients having pleural empyema. Treatment was based on pleural drainage and broad-spectrum antibiotic therapy, along with planning of the appropriate surgery technique to each patient. Surgery consisted in re-thoracotomy and bronchial closure in early detection cases without evidence of infection (< 48 h); thoracostomy (Clagett) and second stage myoplasty if confirmed pleural infection; thoracoplasty in cases of incomplete fistulas that were unresolved by pleural drainage. Biological glues were delivered by fiberoptic bronchoscope in one patient. The incidence of bronchopleural fistula was studied, as were associated factors and the results obtained by various surgical techniques.

Adenocarcinoma↗
PubMed1998

[Surgery of late complications of previous active treatment of lung tuberculosis with extrapleural plombage].

Between January 1984 and February 1997 10 patients with late complications of a former active collapse therapy were operated. In case of our patients between 1943 and 1960 the collaps therapy was carried out with the extrapleural instillation of plombs for therapy of pulmonary tuberculosis. At present main complications were infections of plombs with pleurobronchial and pleurocutaneus fistulas and perforation of plombs. By all patients both extirpation and pleurectomy were necessary. In case of 5 patients additionally lung resection was required, in case of 3 patients a thoracoplasty and by 1 patient a myoplasty. Although there are considerable destructions of lung parenchym in a part the results of long-term follow up are satisfactory: 6 patients are so far without complaints; only 1 patient died 10 years postoperative. Prerequisite for a successful therapy are the knowledge of the surgical methods of the collaps area, the used materials, the pathomorphological pulmonary changes and the good cooperation between pneumologists and thoracic surgeons.

Adult↗
PubMed1976

Postpneumonectomy empyema in pulmonary carcinoma patients. Treatment with antibiotic irrigation and closed-chest drainage.

Seven patients with postpneumonectomy empyema who had had pulmonary carcinoma were treated with intrapleural antibiotic irrigation and closed-chest drainage. Two tubes were used to irrigate and drain the cavity. Although most patients had a bronchopleural or esophagopleural fistula, the treatment was successful in every case. Three of the 7 patients died of far-advanced carcinoma 1 to 2 years postoperatively, but none died of sequela of the empyema. In 3 patients with bronchopleural fistula, empyema recurred during the first postoperative year. However, it responded well to repeated irrigation and drainage. This simple, time-saving, and easily repeatable regimen proved to be both effective and also very comfortable for the patient. It has none of the disadvantages of open thoracic drainage or mutilating thoracoplasty.

Adult↗
PubMedDate not supplied

Post-tuberculosis chronic empyema of the "forty years after".

The authors present 110 cases of patients hospitalized in the last 5 years, with long-term disabling sequelae of pulmonary tuberculosis. Twelve out of them (= 10.9%) suffered from post-tuberculous chronic empyema, with an average latency period of 44.83 years between the acute tuberculous illness and the clinical manifestation of the empyema. Nine of the patients had been treated with collapsotherapy, induced by artificial intrapleural pneumothorax, 1 with thoracoplasty, and 2 only with late and inadequate anti-mycobacterial chemotherapy. Eleven patients (91.6%) also had a cutaneous fistula (7 cases) and/or a bronchopleural fistula (4 cases). The authors show how the issue of tuberculous sequelae is a significant not only from the numerical standpoint, but also for the seriousness of the caused pathological conditions, often posing problems for differential diagnosis. Moreover, they stress how tuberculosis should never be neglected or considered last in the differential diagnosis of empyema and pyopneumothorax.

Adolescent↗
PubMed1998

Fatal complication of paraffin plombage after half a century.

Complications following thoracic plombage for treatment of tuberculosis can be observed more than 50 years after placement of the filling. The management of these late complications is challenging and frequently requires surgical intervention. We report a patient who received a plombage in 1947. She was admitted to hospital with subfebrile temperature and hoarseness. A computed tomography scan of the chest revealed transthoracic penetration of the paraffin plombage with intrusion into the overlying soft tissue. The patient underwent excision and debridement of the paraffin wax mass followed by thoracoplasty. She then developed septicaemia and died due to multiple organ failure 23 days after the surgical intervention. Early ablation of plombage should be considered in order to prevent late complications.

Aged↗
PubMed1998

[Lung cancer in patients with sequelae of tuberculosis].

To clarify features of lung cancer in patients with tuberculosis sequelae, we analyzed data on 15 cases (5.1%) who were diagnosed with lung cancer before death among 294 deceased cases with tuberculosis sequelae at our hospital. There were 12 men and 3 women, with a mean age of 64 years. Most of the 15 patients had pulmonary dysfunction, and 4 had received home oxygen therapy. All 12 men had a history of smoking, and 10 of them had squamous cell carcinoma of the lung. There was no definite correlation between the locations of the tuberculosis lesion and those of lung cancer lesion on chest X-rays. Twelve patients had had thoracoplasty for tuberculosis, and in 6 of these patients the lung cancer occurred in the same lung. Lung cancer was apt to be diagnosed in an advanced stage. However, in patients who received home oxygen therapy, diagnosis had been made at an early stage because of the frequent chest X-ray follow-up. We conclude that lung cancer is an important complication in patients with tuberculosis sequelae, and early diagnosis of lung cancer by careful follow-up is essential in the care of cases with tuberculosis sequelae who have poor pulmonary function and/or systemic conditions.

Aged↗
PubMed1998

[Diagnosis and treatment of pulmonary tuberculosis complicated with chronic liver disease].

Immunocompromised or malnutritional hosts are high risk group of pulmonary tuberculosis. Chronic liver disease especially decompensated cirrhosis of the liver is one of the risk group for this infection. When ascites or pleural effusion developed in patient with hepatic cirrhosis, complication of pulmonary tuberculosis must be considered. In such condition, drug metabolism was impaired so that anti-tuberculous drugs should be used carefully, but in almost cases except decompensated cirrhotic patients are tolerable for standard anti-tuberculous combination therapy and they could be cured. Hepatitis C virus infection is common in patients with old pulmonary tuberculosis because many of them were infected Hepatitis C virus at the time of blood transfusion for pulmonary resection or thoracoplasty. In such condition recurrence of pulmonary tuberculosis is rare but probability of recurrence must be considered when they developed decompensated cirrhosis.

Chronic Disease↗