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PubMed2006

[Penetrating thoracic injury].

PURPOSE: To clarify the clinical aspects of penetrating thoracic injury. PATIENTS AND METHODS: Eighteen patients with penetrating thoracic injury treated from 1987 to 2005 were evaluated. There were 13 men and 5 women. The age distribution was 8 to 69 years, with an average of 36.7 years. RESULTS: There were 14 patients with stab wound and 4 with impalement injury. Five patients with stab wound were those who attempted suicide. In 4 patients with impalement injuries, the cause was fall in 2, traffic accident in 1 and sports injury in 1. The calculated injury severity score (ISS) was over 15 in 4 patients, 6 to 14 in 12, and under 5 in 2. Thoracotomy was performed in 2 patients with cardiac tamponade, 3 with massive hemothorax and 1 with an impalement injury caused by an iron bar. All of them were rescued and got well. In the other cases, after cleansing and debridement, the wound was closed and thoracic drainage was performed. Only 1 patient with cardiac arrest on arrival died within 24 hours after reviving. CONCLUSIONS: Emergent thoracotomy is indicated for patients with massive bleeding including shock, continuous air leakage and cardiac tamponade. Since cardiac arrest is difficult to cure, appropriate cooperation with the rescue team is necessary to avoid preventable trauma death.

Adolescent↗
PubMed2006

[Safety and efficacy of resection of hemivertebrae by posterior approach in treatment of thoracolumbar kyphoscoliosis in adolescents].

OBJECTIVE: To investigate the safety and efficacy of resection of hemivertebrae by posterior approach in treatment of thoracolumbar kyphoscoliosis in adolescents. METHODS: twenty-eight patients of kyphoscoliosis, 19 male and 9 female, aged 12 approximately 16, 12 cases with the hemivertebra located in T(12), 10 cases in L(1), and 6 cases in T(11), and with a mean angle of 75 degrees in kyphosis and 48 degrees in scoliosis by the Cobb measurement, underwent resection of the hemivertebrae via the posterior approach and were followed up for 3.5 years. RESULTS: The mean surgical time was 3.7 hours and the average blood loss was 900 ml. Intercostal neuralgia occurred in one patient and relieved automatically without treatment. Hemothorax and pneumothorax were found in two cases during the operation and were healed after 1 week. Solid fusion was obtained in all the patients. The Cobb measurement was 19 degrees in kyphosis and 14 degrees in scoliosis on average at the final follow-up. No neurological deficit and infection was noted in the late stage. Clinically, no spinal imbalance or trunk shift was observed in all patients. CONCLUSION: Resection of hemivertebrae via posterior approach is safe and effective in the treatment of thoracolumbar kyphoscoliosis in adolescents.

Adolescent↗
PubMed1991

[Surgical therapy of HCG-producing mediastinal tumor accompanied with intrapulmonary metastasis].

The patient is a 31-year-old man who was suffering from hyperthyroidism and left hemothorax. His serum HCG level was extremely elevated and chest X-ray showed a mass shadow of anterior mediastinum and bilateral multiple intrapulmonary metastasis. Our clinical diagnosis was primary HCG-producing germ cell carcinoma of mediastinum and immediately administered CDDP and VP-16. Chemotherapy was effective and tumor extirpation was carried out for mediastinum and lungs by median sternotomy. All of the resected specimen showed no cancer cells and 4 years have passed with no evidence of recurrence. Aggressive surgical approach is indicated for mediastinal germ cell carcinoma accompanied with intrapulmonary metastasis when chemotherapy is effective.

Adult↗
PubMed1991

[Mediastinal hematoma due to thymoma hemorrhage--a case report].

A 70-year-old man came to our hospital complaining mainly of acute dyspnea. A chest X-ray, echocardiogram, and chest CT showed a mediastinal mass, and pericardial and pleural effusions. A thoracotomy revealed a cystic tumor along the thymus. The tumor contained bloody fluid, coagula, and fibrin calculi. Rapid specimens showed no tumor cells and the hematoma was assumed to have been caused by the thymus. Therefore, a thymectomy was performed and as much of the hematoma as possible was removed. After the operation, a careful pathological examination revealed a thymoma with a diameter of about 7 mm. In addition, coagula and fibrin calculi contained some tissue from the thymoma, and the diagnosis was made that a mediastinal hematoma had formed due to hemorrhage from the thymoma. Several cases of mediastinal tumor of cyst hemorrhages in the thorax have been reported. However, only a few cases of thymomal hemorrhages in the thorax have been reported; one case each of mediastinal hematoma, hemothorax, and cardiac tamponade. Great care is necessary when dealing with atraumatic mediastinal hematomas if malignant tumors such as thymoma are present.

Aged↗
PubMedDate not supplied

Severe injuries resulting from operations for thoracic outlet syndrome: can they be avoided?

Surgery for thoracic outlet syndrome (TOS) is claimed to have a low risk of severe complications. To re-evaluate this, a questionnaire was sent out to the French vascular surgical community. There were 66 replies. While some surgeons had operated on several hundred patients without any severe complications, others had experienced rare but dramatic complications including wounds or thrombosis of the axillary artery, vein injuries or thrombosis, transient or definitive paralysis of the brachial plexus, long thoracic or phrenic nerves, hemothorax, and chylothorax. Two resulted in the death of young patients. The results of the present study, as well as rare reports in the literature, demonstrate that these complications may occur even with experienced surgeons using either the supraclavicular or transaxillary approaches. We conclude that: (1) operation for TOS should be considered only when the diagnosis is certain and when operative decompression is the sole solution; (2) the choice of an adequate approach, good vision during operation, and meticulous technique are all mandatory for full security. Surgical guidelines are suggested.

Arm↗
PubMed1991

[A case report of emergency surgical repair of traumatic transection of thoracic descending aorta].

The injury to the thoracic aorta caused by blunt chest trauma is often fatal. This case is 22-year-old male suffering from transection of the thoracic descending aorta caused by traffic accident. He was transported to our emergency room by an ambulance 15 minutes after the accident. Hundred fifty minutes after arrival to the hospital, we were rush to bring him to the operation theater suspecting serious injury of the thoracic organs in association with left hemothorax. The left standard thoracotomy disclosed the injury of the thoracic descending aorta. Simple cross clamp was applied to the thoracic descending aorta distal to the left subclavian artery for 20 minutes. Completely transected aorta was reapproximated using monofilament 3-0 polypropylene sutures with running manner. He tolerated the procedure well without any complication. His postoperative course was uneventful. He was followed up at the orthopedic department for associated hip fracture thereafter.

Accidents, Traffic↗
PubMed1991

[Ambulatory evaluation and treatment of blunt thoracic injuries].

307 patients with chest injuries were treated in an outpatient clinic during a three month period. Ten patients developed complications such as hemothorax, pneumothorax and lung contusion, or late complications such as atelectases and pneumonia. 21 patients were hospitalized after initial evaluation. Two patients died. Pain was a symptom in 306 of the 307 patients. Other symptoms were coughing, hempoptysis, fever, nausea. Complications increased in 40 patients, with other symptoms or signs in addition to pain. These other symptoms had a 40% positive and 95% negative predictive value as regards complications. 45 out of 114 patients had a pathological chest x-ray. Positive chest x-ray had a 40% positive and 94% negative predictive value as regards complications. In four patients (1.3%) complicating injuries were not identified initially. Five of 24 patients (21%) were hospitalized unnecessarily. Chest x-ray should be performed in patients with additional symptoms and signs. Patients with no signs in addition to chest wall tenderness can be observed at home.

Adolescent↗
PubMed1991

[Blunt thoracic injuries in Oslo].

All 327 patients treated in Oslo City Hospital for blunt chest injuries during a period of three months were registered prospectively. 274 were treated outside hospital. Traffic accidents accounted for 10% of the total number of patients, but 40% of the hospitalized patients. Accidents in the home were most numerous, with many complications and admissions to hospital. 20% of the hospitalizations, were for injuries due to violence. The registration indicates more than 1,300 patients with chest injuries per year, of whom more than 40 are severely multitraumatized. The chest injury was serious in 21 patients, moderate in 306. 13.5% of the cases were complicated by pneumo-hemothorax and lung contusion, or by late complications such as pneumonia and atelectases. Seven patients (2.1%) died. These were old, physically disabled or multitraumatized. 100 patients had extrathoracic injuries, of whom 15 had intrathoracic injuries as well. In 227 patients with thoracic injuries only, the injuries were intrathoracic in six of them. The mortality in patients with chest wall injuries only was 0.7%, as compared with 20% in patients with intrathoracic injuries.

Accidents↗
PubMed1991

[Mitral commissurotomy with extracorporeal circulation. Apropos of 200 cases with a median survival of 15 years].

This is a retrospective study of 200 patients, with long-term results operated upon from October 1965 to July 1984. 83% women, 17% men. The mean age was 42.40 +/- 11.03 years. In 87% mitral stenosis was pure and 13% systolic murmur was heard. 60% were in classes III and IV and 40% in classes I and II (NYHA). Hemodynamically mean C.W.P. was 21 +/- 6.27 mm Hg and mean P.A. pressure 30 +/- 9.5 mm Hg. Right anterior thoracotomy was done in every case with canulation of femoral artery and V.C. extracorporeal circulation consisted of a bubble oxgenation (RYGG) and a Roller Pump. In 88.5% both commissures were opened and in 11.5% only the anterolateral commissure. In 58% both papillary muscles were incised, in 15% anterolateral and in 13% posteromedial papillary muscles were incised. In 17% valves or commissures were decalcified. In 5.5% a thrombus was removed from the auricle. Postoperative mortality was 0%. 13% of patients experienced a postoperative complication: 4% hemothorax, 2.5% gaz embolism without sequela, 0.5% lower extremity embolism, 3% pulmonary embolism, 2% phlebitis and 1% gastrointestinal haemorrhage. Postoperatively in 75% of cases no murmur was heard, and in 25% a systolic murmur was found over pericardium. 167 patients were assessed at a mean interval of 129.88 months. 11 patients died at a mean interval of 98.56 +/- 48.56 months with non cardiac cause in 9 cases.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1991

Diagnostic efficacy of pleural biopsy as compared with that of pleural fluid examination.

Previous studies compared the diagnostic value of pleural fluid cytology versus pleural biopsy. No direct comparison of the procedures including data from a combination of all diagnostic tests performed on each specimen appears to have been done. A total of 385 patients with concurrent pleural biopsy and fluid examination were identified from 1973 to 1986. Clinical records, histologic and cytologic preparations, and microbiologic and chemical data were reviewed. A total of 109 patients had a final diagnosis of malignancy. Cytology was diagnostic in 71% and "suggestive" in an additional 8%. There were no false-positives but, in two patients with pulmonary infarcts, the effusions were reported as "suspicious." Pleural biopsy was positive in 45%, including three cases with negative cytology. In 71 patients with tuberculosis, the pleural biopsy was diagnostic in 49%. A cytologic picture suggesting the diagnosis was present in 68%. Cultures of the biopsy yielded Mycobacterium tuberculosis in 23% of cases, while pleural fluid was positive in 30%. In six cases, the only confirmatory evidence of tuberculosis was pleural culture. In 205 patients, none of the above procedures provided specific diagnoses. A combination of biopsy and fluid examinations improves the diagnostic sensitivity. Pleural biopsy increases the rate of complications and did lead to fatal hemothorax in two patients. These results support the superiority of pleural fluid examination in the diagnosis of malignancy. In addition, they demonstrate the value of pleural fluid examination in the diagnosis of tuberculosis.

Adolescent↗
PubMedDate not supplied

[Problem of patient's consent to surgical treatment in life-threatening situations].

A case of a self-injury in a 19-year man is presented. The patient stabbed his thorax with a needle (a wire 9 cm long) which penetrated the right lung near the heart. The patient did not agree to the operation. Left cardiac auricle laceration with hemothorax and pericardial tamponade developed within 13 days. The authors suggest immediate surgery despite patient's disagreeing or even rebel in all situations threatening the lives of the prisoners or convicts. Two ++sub-periods might be distinguished in the above mentioned situation: (a) potential, and (b) real life-threat. Surgery should have been performed in the potentially life-threatening ++sub-period in this particular patient.

Adult↗
PubMed1990

[Experience with implantation of a permanent electrode for cardiac pacing directly through the subclavian vein in 2,309 patients].

Since April 1975 to the end of 1988 permanent cardiac stimulation was employed in 2,309 patients. The stimulating electrode was placed in the right ventricle in 2,258 patients and in the right atrium in 29 patients. Two electrodes were introduced in 22 patients one in the right ventricle and the other in the right atrium. All electrodes were introduced directly through the subclavian vein. No other approach was used. Serious complications appeared in 4 patients (i. e. in 0.17%). Pneumothorax on the side of the introduced electrode occurred in 3 patients. One woman of 80 died in connection with this complication. Another woman, who was overdosed with Pelentan, experienced hemothorax on the side of electrode insertion. After drug discontinuation and thoracic puncture the patient was doing well. In our opinion the subclavian approach for permanent electrode introduction is much more convenient than the introduction via either the cephalic or the jugular vein respectively. The former approach is considerably quicker and less traumatic in use. This method may be used in practically all patients. The repetitive introduction of the electrode through the same subclavian vein is much appreciated in patients in whom a new electrode has to be introduced. This method may be used for right atrium stimulation and for sequential pacing as well.

Cardiac Pacing, Artificial↗
PubMed1990

Chest injuries in the trauma patient.

The primary survey of a trauma victim always begins with the ABCs used in resuscitation. Chest trauma compromises the normal physiology of respiration and circulation. Although some chest injuries are overt, some are not. The mechanism of injury is important for increasing the degree of suspicion used to identify covert injuries. The most lethal injuries include tension pneumothorax, sucking chest wound, massive hemothorax, flail chest, and cardiac tamponade. Cardiac and aortic ruptures often cause death before the victim enters the health care system. Potentially lethal injuries include myocardial and pulmonary contusion, tracheobronchial disruption, and esophageal disruption. Trauma victims present with many combinations of chest injuries. The care of these patients is very complex. Nursing diagnoses guide the care of chest trauma patients and can include impaired gas exchange, alteration in cardiac output, and altered breathing pattern. The goal of treatment is to restore and maintain stable hemodynamics with adequate respirations and circulation allowing definitive treatment for a positive patient outcome.

Aorta, Thoracic↗
PubMed1990

[Giant cell tumor of the bony thorax].

Two cases of giant cell tumor of the bony thorax are described. Case 1 presents a 21-year-old female with a recurrent giant cell tumor of the third and the fourth thoracic vertebrae that directly compressed the membranous portion of the trachea and brought about severe air way obstruction. The tumor was completely resected and the patient remains healthy without recurrence 30 months after surgery. Case 2 presents a 18-year-old female with a giant cell tumor invading transverse process of the seventh thoracic vertebra and the seventh rib and making a big mass in the thoracic cavity on the right side. This patient was first seen with hemothorax and treated just by tube drainage three months before undergoing total resection of the tumor. She remains well nine months after surgery.

Adolescent↗
PubMed1990

Rupture of thoracic aorta caused by blunt trauma. A fifteen-year experience.

During the 15 years from 1971 through 1985, 114 patients with rupture of the thoracic aorta caused by blunt trauma were admitted to the Shock Trauma Center of the Maryland Institute for Emergency Medical Services Systems. Mean age was 31.3 years (range, 15 to 80). Ninety were male and 24 were female, a 3.75:1 ratio. Of the 114, 89 (78.1%) survived initial resuscitation in the admitting area. Twenty five of the 89 initial survivors (28.1%) died during or after surgical repair. Paraplegia occurred in 11 of the 78 operating room survivors (14.1%). Further analysis was done of the 83 patients admitted in the 10-year period from 1976 through 1985. Mean Injury Severity Score, excluding aortic injury, was 18.2. Twenty-five of the 83 (30.1%) died during resuscitation in the admitting area or operating room. Seven others died during surgical repair and 12 died postoperatively, leaving 39 survivors (39/83 [47%] of total admissions and 39/58 [67.2%] of survivors of resuscitation). Paraplegia/paresis developed postoperatively in six of 34 (17.6%) cases involving shunt and four of 17 (23.5%) without shunt. Other major complications occurred in 21 of the operating room survivors. Statistically significant risk of death or major complication was associated with female sex, higher Injury Severity Score, lower admission blood pressure, larger hemothorax on admission, less qualified surgeon, major operation before aortic repair, use of shunt, and transfer directly from scene of injury. There was no advantage in this series to using or not using a shunt in preventing paraplegia. Mortality rates are realistic for a highly developed trauma system. Better techniques are needed to manage exsanguination and prevent paraplegia.

Adolescent↗
PubMed1990

[A case of ruptured azygos vein and diaphragmatic hernia due to blunt chest trauma].

A 47-year-old female was admitted to the emergency room following an automobile accident. She was shocked complaining of respiratory difficulty and chest pain. A chest X-ray showed right hemothorax which drained 2.5 liters of blood on insertion of chest tube. Emergency operation revealed rupture of azygos vein. The bleeding was controlled by the ligation of the azygos vein. Postoperative chest X-ray showed obscuration of the left diaphragma, and herniated stomach was identified by the gastrography. Second operation was performed and ruptured diaphragma was repaired. Her postoperative recovery was good. She was discharged from hospital at 7th week.

Azygos Vein↗
PubMedDate not supplied

Heart transplantation for intractable prosthetic valve endocarditis.

A 25-year-old woman with active systemic lupus erythematosus and infective endocarditis was seen initially with porcine aortic bioprosthetic stenosis, perivalvar regurgitation, and native mitral regurgitation 9 years after aortic valve replacement for lupus endocarditis. Double-valve replacement was performed with St. Jude Medical mechanical prostheses. After operation the patient developed fever and an elevated white blood cell count. One month later she had increasing mitral and aortic perivalvular regurgitation and intermittent complete heart block. At reoperation both annuli showed evidence of continued infection, and she underwent annular reconstructions with pericardium and double-valve re-replacement. Cultures grew Mycoplasma hominis. Despite long-term therapy with appropriate antibiotics, within 2 months she developed recurrent perivalvar regurgitation with congestive heart failure. Orthotopic heart transplantation was performed. The postoperative course was notable for significant leukocytosis and spontaneous culture negative hemothorax that required thoracotomy for drainage. The patient recovered and is now well 14 months after operation.

Adult↗
PubMed1990

Blunt aortic trauma: signs of high risk.

In the last 10 years, our center has managed 60 cases of aortic rupture from blunt chest trauma. Nineteen patients died (32%), 11 of whom were moribund on admission. Two patients out of ten who had undergone aortography at other institutions arrived at our hospital with massive bleeding in the left chest and died despite immediate operation. Six patients exsanguinated 1 to 2 1/2 hours after admission while aortography was being arranged or performed, and review of these cases to identify clinical signs of high risk revealed that left hemothorax, pseudocoarctation, and/or supraclavicular hematoma were present in five of the six. It appeared that the survival rate of patients suspected of blunt aortic trauma who had any of these clinical signs might be improved if they were taken directly to the operating room. To investigate this possibility we reviewed all cases from the past 10 years (excluding patients moribund on arrival or who had aortography elsewhere) in whom suspicion of aortic trauma led to aortography or surgery. Thirteen of the 17 patients (76%) with one or more signs of high risk had torn the aortic isthmus, compared to 26 of 154 patients (17%) without these signs. Five of the high-risk group (29%) exsanguinated, compared to one (less than 1%) of the others. No patient in this series died from unsuspected aortic trauma, which we attribute to the liberal use of aortography. Except for the patients with exsanguinating hemorrhage preoperatively, there were no operative or postoperative deaths.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗