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PubMed1993

[A case of impending rupture of acute aortic dissection with thrombosed false lumen in early phase].

A 73-year-old patient with acute aortic dissection in delayed shock state following sudden onset of chest-back pain and left sided hemothorax was successfully operated. Contrast enhanced CT demonstrated a crescent-shaped low density area in the descending aorta. Aortography showed ulcer-like projection (ULP) with minor leakage into left thorax, however, a flow in false lumen was not visualized. These findings suggested that the false lumen of type III aortic dissection was thrombosed in its early phase. The aneurysm was transected on left heart bypass through left thoracotomy. The entry of false lumen was found in proximal portion of descending aorta, in which fresh thrombus was filled. A graft was anastomosed and reinforced with felt strips in end-to-end. The postoperative course was uneventful. The ULP by aortography provides a possible sign of rupture in clinical course of aortic dissection.

Aged↗
PubMed1993

[A case of Rendu-Osler-Weber disease associated with pulmonary arteriovenous fistula].

A 60-year-old female was admitted with a chief complaint of left hemothorax. Chest X-ray films revealed an abnormal shadow when the pleural effusion disappeared. On the physical examination, multiple telangiectases were found at the nasal mucosa, tongue and stomach. The family history showed that her son experienced frequent episodes of epistaxis. The patient was diagnosed to have Rendu-Osler-Weber disease. CT scanning and pulmonary angiography showed an arteriovenous fistula of the left lower lobe (S10) and cerebral angiography did a small arteriovenous fistula in the cerebellum. Pulmonary partial resection was performed to prevent re-hemorrhage. Pulmonary arteriovenous fistula was 2.5 x 1.5 cm in size. It located in the left lower lobe exposing through the surface of the lung over the diaphragm. The postoperative course was uneventful and she was discharged on the 18th postoperative day without any complications.

Arteriovenous Fistula↗
PubMed1993

[Video-thoracoscopic atypical lung resection].

A new era in thoracoscopy within the framework of minimal invasive thoracic surgery was introduced due to the possibilities of video-endoscopy, the development of an accordingly advanced and suitable instrumentarium as well as the production of an endoscopically applicable linear stapler. The introduction of the endo-staplers has made the thoracoscopic resection even of larger parts of lung parenchyme possible. Just as in laparoscopy a clear reduction of post-operative pain, a reduced impairment of post-operative pulmonary function, a shorter in hospital stay and an earlier return to normal activities are advantages of thoracoscopy when compared to the severely more traumatising thoracotomy. Good indications for this procedure are the spontaneous pneumothorax and the resection biopsy in the quest of finding the diagnosis of unclear pulmonary disease. For the diagnostic and should the situation arise therapeutic resection of solitary pulmonary nodules in contrast a stricter selection and handling of indications is imperative. The method however proved worthwhile under such conditions. The technique and results are reported of video thoracoscopies in 73 patients as well as 51 atypical lung resections carried out thoracoscopically with the Endo-GIA 30. A switch to open thoracotomy became necessary in 16.4%. Indications were pneumothorax (35.6%), hemothorax (1.3%), diagnostic resection of solitary nodule (42.5%), pneumopathy (11.0%), and extrapulmonary tumor (9.6%). Atypical resections were carried out only in the case of solitary nodule (51.7%), pneumothorax (39.7%), and pneumopathy (8.6%). A histological diagnosis was obtained in all cases. The average operating time for solitary nodule and pneumothorax was 1 hour, for pneumopathy 1/2 hour. Chest drains could be removed after 1.6-2.6 days. The postoperative complication rate amounted to 3.9%. There was no mortality. The introduced procedure represents a new and promising alternative in thoracic surgery.

Adult↗
PubMed1993

Penetrating chest trauma.

This article reviews the current concepts in penetrating chest trauma. The authors discuss mechanisms of injury, nursing assessment, and interventions for penetrating injuries resulting in cardiac rupture, cardiac tamponade, tension pneumothorax, hemothorax, great vessel injury, and sucking chest wounds.

Critical Care↗
PubMed1993

[Chylothorax: a rare complication of transaxillary thoracic sympathectomy].

Transaxillary upper thoracic sympathectomy is a safe surgical procedure for the treatment of palmar hyperhidrosis. Although thoracic complications such as hemothorax and pneumothorax occasionally occur following this procedure chylothorax is an extremely rare complication. From 1978 to 1991, 215 consecutive patients underwent upper thoracic sympathectomy for the treatment of palmar hyperhidrosis in our institution. We report the surgical management of one patient who developed an intractable chylous fistula which did not respond to non-surgical treatment. Attempts at non-surgical management of the disease, with aspiration therapy, tube thoracostomy and the administration of medium chain triglyceride diet, should be tried first. If, however, this is not successful within two weeks, one should not wait for further metabolic and nutritional impairment before instituting surgical treatment. We believe that proximal thoracic duct ligation is a relatively simple and effective means of controlling chylothorax.

Adolescent↗
PubMedDate not supplied

The role of interventional cardiology in pediatric heart transplantation.

Hypoplastic left heart syndrome (HLHS) is the most common cause of cardiac death during the first week of life. The prognosis of this fatal malformation has changed completely since the introduction of neonatal heart transplantation. However, patients awaiting a heart donor are at high risk for closure of the ductus arteriosus and are exposed to complications from indwelling central venous catheters and long-term use of prostaglandin E1. To maintain the ductal patency, which is crucial for the survival of these patients, we performed a stenting of the ductus arteriosus in six infants with HLHS using a 2 cm length balloon expendable stent. Age ranged from 5 to 92 days and weight ranged from 2.1 to 5.4 kg. Successful stenting with subsequent hemodynamic stability was obtained in all the patients. Patient 4 died 24 hours after stenting from hemothorax related to an attempted subclavian catheter placement. Heart transplantation was successfully performed in patients 1, 2, 3, and 5 at 15, 1, 50, and 8 days after stenting, respectively. Patient 6 underwent successful heart transplantation 157 days after ductal stenting.

Biopsy↗
PubMed1993

[Traumatic primary brain stem injury and ambient cistern hematoma evaluated with magnetic resonance imaging].

Traumatic hemorrhage in the ambient cistern is thought to be an indirect indication of brain stem injury. In many cases such brain stem lesions cannot be clearly demonstrated by conventional CT scans. Magnetic resonance imaging (MRI) provides a more sophisticated display of the brain stem with improved contrast resolution of structures not appreciated on CT. We present four patients with traumatic ambient cistern hematoma on CT. They showed consciousness disturbance at the initial neurological examination and a Glasgow Coma Scale (GCS) of 7-10. All patients had hemothorax or clavicular fracture ipsilateral to the ambient cistern hematoma that suggested a severe mechanical force from the same direction. Axial, coronal and sagittal MRI scans were obtained with a super-conductive 1.5 T unit (Picker) within 6 days after trauma. Two standard pulse sequences were used; (1) Spin-echo (TR/TE = 500/20) or Inversion Recovery (TR/TI/TE = 3300/600/30) to obtain T1-weighted information and (2) Spin-echo (TR/TE = 2000/100) to obtain T2-weighted information. In case 1 (3-year-old girl) the hematoma which was thought to be located in the ambient cistern on CT was found to be present in the subpial region in the tegmentum on MRI. On T2 weighted image, a high signal intensity area was seen in the perifocal area. This area was demonstrated as a low density area on CT. This patient has remained in a persistent vegetative state 6 months after trauma. In case 3 (31-year-old man) CT demonstrated no abnormal findings in the brain stem. MRI demonstrated a high intensity area in the right cerebral peduncle and left tegmentum.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1993

[Case report of metastatic cutaneous angiosarcoma causing bilateral pneumothorax].

The patient was a 72-year-old man who underwent operation for bilateral pneumothorax due to rupture of cystic lung lesions. Two months after the operation, intrathoracic bleeding redeveloped. The patient developed a tumor on his head. Pathological examination of the scalp lesion revealed cutaneous angiosarcoma. A biopsy of thickened pleura showed that the bleeding was due to pleural metastatic angiosarcoma of the skin. The multiple cystic lesions were considered to be metastases of angiosarcoma. We conclude that pneumothorax or hemothorax in the elderly should be differentiated from malignant metastatic lung tumor. Cystic lung lesions should be considered as possible metastatic angiosarcoma from the skin.

Aged↗
PubMed1995

[Successful valvuloplasty for isolated tricuspid regurgitation due to traumatic ruptured papillary muscle].

A 44-year-old man suffered from an traffic accident on May 27, 1994. He was transferred to a hospital because of emergent operation for a laceration of liver, right-sided hemothorax and pneumothorax. After surgical treatment for these lesions, he was doing well. However, systolic murmur appeared from August, 1994. By echocardiography and cardiac catheterization, he was diagnosed of isolated tricuspid regurgitation due to traumatic ruptured papillary muscle. Because right heart failure was progressive, an operation was recommended. At operation, annular dilatation of tricuspid valve and ruptured papillary muscle of anterior leaflet were found. And the ruptured end of right ventricular aspect was recognized. Therefore, we performed tricuspid valvuloplasty and annuloplasty. Postoperative course was uneventful. And residual regurgitation was not detected by right ventriculography. Especially, in patients with tricuspid regurgitation due to ruptured papillary muscle, symptoms usually begin soon after trauma. Therefore, an operation should be recommended promptly in the presence of right heart failure not relieved by medical treatment. And an earlier operation could increase the feasibility of tricuspid valvuloplaty, and the possibility of maintaining sinus rhythm.

Adult↗
PubMed1995

[Diagnostic role of the combination of computerized tomography and angiography in traumatic injuries of the thoracic aorta].

AIM: To assess the diagnostic value of the combination of computed tomography and angiography in patients with blunt thoracic trauma and suspicion of aortic injury. PATIENTS AND METHODS: Retrospective analysis of six patients, aged 22 to 72 years old, with traumatic thoracic aorta injury secondary to severe trauma, specially car accidents, seen between 1985 and 1994. RESULTS: An early diagnosis was done in three patients. One patient, in whom diagnosis was delayed, died before surgery. In three cases, CAT scan showed indirect evidence of aortic rupture, consisting in alterations of aortic outline. In other three patients, it showed hemomediastinum, associated to a left hemothorax in one case. Angiography confirmed the diagnosis, localized and characterized the injury in all patients. CONCLUSIONS: The delay in the diagnosis of aortic injury may be fatal. The combination of CAT scan and angiography has a high sensitivity and specificity to localize and characterize lesions of the aorta or its branches or associated organs, essential step for surgical planning. CAT scan restricts the use of angiography, avoiding false negative studies, but cannot be used as the sole diagnostic procedure.

Adult↗
PubMedDate not supplied

[Errors and difficulties in emergency x-ray diagnosis of traumatic ruptures of the diaphragm].

A clinical and x-ray analysis of 30 cases with closed ruptures of the diaphragm and concomitant injuries is presented. Some aspects in the methodology of x-ray examination of patients with grave combined injuries are discussed and the importance of early contrast examination of the gastrointestinal tract emphasized. The author analyzes the difficulties associated with and errors occurring in x-ray examination. Some errors may be due to inappropriate timing of x-ray contrast examination. Rupture of the diaphragm may have no clear-cut x-ray signs in the first hours of the injury because of hemothorax, but a dynamic x-ray monitoring helps timely diagnose it.

Adolescent↗
PubMed1995

[Thoracic trauma].

From January 1989 to December 1992, in the Institute of Clinical Surgery of the University of Perugia, 102 patients were admitted for thoracic trauma. Two patients with an open thoracic trauma, both presenting multiple shot-wounds, underwent an explorative thoracotomy. One of them died on the operating-table from hemorrhage, while the other was saved by a wedge-resection. A 3rd explorative thoracotomy was successfully performed on a patient with internal thoracic trauma and severe hemothorax. Among the 100 patients with an internal thoracic trauma, mortality was 6%, but only one of the 6 deceased, had no lesions other than a fail chest. As a matter of fact 38 patients presented lesions in other parts of the body. Simple and complicated multiple costal fractures, found in 84 cases, were the most frequent lesions observed. Seventeen of the 38 patients with pneumothorax and/or pleural effusion had a chest tube applied. Three patients were operated for a diaphragmatic hernia with a positive outcome. Only 75 patients received medical treatment without surgery. Six of the patients with multiple costal fractures presented flail chest. One of them (mentioned above) died almost immediately after his admission and therefore received no more than the initial medical treatment. Four others, aged over 65, successfully underwent a costal osteosyntesis, while the 6th patient received medical therapy with a positive outcome. In the case of a critical flail chest with severe patho-physiological consequences, if the fractures are in technically favourable sites, the Authors believe it is better to immediately stabilize the thorax, since the operating trauma is minimum and in many cases the patient is already intubated and curarized.

Adult↗
PubMed1996

Lymphoplasmacytic aortitis and acute aortic dissection. An uncommon association.

A 43-year-old white man with a history of cigarette smoking, hypertension, nephrolithiasis, and cervical degenerative arthritis was hospitalized for sudden-onset severe, substernal, and pleuritic chest pain with epigastric radiation. Despite evaluation, the cause remained unclear and the patient expired on hospital day 5. Autopsy revealed acute Stanford type A aortic dissection, hemopericardium, and hemothorax. Grossly, the aorta and its branches, including uninvolved medium-sized arteries, displayed extreme mural fragility. Microscopic examination showed a primary lymphoplasmacytic aortitis-periaortitis without giant cells. Rents within the tunica media, medial-adventitial inflammation, and elastic fiber disruption were limited to sites of gross aortic dissection. Muscular arteries showed patchy, chronic arteritis-periarteritis without giant cell infiltrate or aneurysm formation. This case documents an unusual association of primary lymphoplasmacytic aortitis and aortic dissection.

Adult↗
PubMed1996

Preliminary experience with split liver transplantation.

BACKGROUND: The purpose of split liver transplantation is to alleviate the organ shortage for patients with end-stage liver disease. The procedure, however, has not gained wide acceptance. This is related not only to the complexity of the procedure but also to poorer results and the complications reported to be associated with the technique. STUDY DESIGN: We report 12 split liver transplantation procedures, seven in children and five in adults. Selection criteria were the same as those for whole-size liver transplantation. Patient and graft survival as well as complications were analyzed. Results were analyzed by Wilcoxon life tables. RESULTS: Patient and graft survival rates are 91.6 and 75 percent, respectively. One patient died at 2.5 months after transplantation because of lymphoproliferative disease. Another had acute vanishing bile duct syndrome and required retransplantation at 1.5 months. One patient had retransplantation because of hepatic artery thrombosis. Bile leaks occurred in two patients and hemothorax in one patient. CONCLUSIONS: Our results indicate that split liver transplantation has become a more acceptable method of hepatic transplantation and should be encouraged. Several guidelines can enhance success rates.

Adult↗
PubMed1996

A calf model for left ventricular centrifugal mechanical assist.

The increased use of centrifugal mechanical assist (CMA) for treatment of refractory postcardiotomy cardiogenic shock highlights the need for experimental testing to improve clinical results. This report describes the preoperative conditioning, anesthetic and surgical technique, and postoperative management of a reliable calf model refined in this laboratory for in vivo subchronic (96 h) testing of CMA. Holstein bull calves (2 to 3 months old; mean body weight, 78 kg; n = 35) were instrumented for left ventricular CMA; 4 of these calves were sham-operated controls. Anesthetic recovery and postoperative restraint were accomplished in a specially designed crate to which each calf was preconditioned extensively. Younger calves were more readily conditioned and more tolerant of postoperative restraint than older calves. One calf died of ventricular fibrillation intraoperatively. One calf that had been heparinized developed uncontrollable hemothorax and died 12 h postoperatively. One calf prematurely dislodged his aortic cannula 15 h postoperatively and exsanguinated. Six calves developed pelvic limb paresis or paralysis because of lumbar spinal cord thromboembolism by 36 h postoperatively, and 3 of these calves were sacrificed by 42 h postoperatively. Fifteen calves required sedation in the first 12 h after the operation. Tachycardia associated with bottle feeding occurred in 15 calves. Second-degree atrioventricular block was noted frequently during deep relaxation. Postmortem examination demonstrated the absence of surgical wound and distant infection, security of cannulae in all but the calf that prematurely dislodged the aortic cannula, absence of thrombus formation at cannulation sites, and presence of thromboembolism in 51% of the calves. The incidence of thromboembolic lesions was not influenced by the need for chemical restraint, by the occurrence of feeding-associated tachycardia, or by the presence of atrioventricular block. There were no thromboembolic lesions in any of the sham-operated controls.

Anesthesia↗
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

[Effective treatment of a man with head injury and multiple rib fractures with epidural analgesia].

A 46-year-old man involved in a traffic accident was admitted to our university hospital for treatment of acute subdural hematoma of the brain, multiple rib fractures and hemothorax. On admission, he manifested disturbance of consciousness, and his left upper and lower extremities were paralyzed. Blood gas analysis revealed hypoxia, and he was nasotracheally intubated. He was mechanically ventilated with 10 cmH2O positive end-expiratory pressure for treatment of rib fractures following surgical removal of the subdural hematoma and insertion of a sensor into the epidural space for measurement of intracranial pressure. Despite continuous intravenous infusion of midazolam and buprenorphine, he was agitated and thrashed from side to side, probably due to severe chest pain caused by rib fractures. Agitation was effectively controlled by continuous thoracic epidural administration of morphine and bupivacaine. Intracranial pressure did not increase, and epidural analgesia was without sequelae. The patient's level of consciousness gradually improved, rib fractures were treated and he was extubated on the 25th hospital day. These findings indicate that epidural analgesia is useful for controlling pain-related agitation caused by head and chest injuries if increased intracranial pressure is not present.

Accidents, Traffic↗
PubMed1996

Blunt thoracic trauma in children.

Thirty four children with blunt thoracic trauma were treated at the university hospital, Trabzon. Eighteen of them were sustained in motor vehicle accidents, 14 were falls and two were a result of miscellaneous causes. Rib fracture developed in 16 patients and pulmonary contusion occurred in 18 patients. Pneumothorax existed in 19 patients, and hemothorax was noted in ten patients. Traumatic asphyxia occurred in seven patients. Associated head, abdominal, and orthopedic injuries were present in 21 patients. Chest drainage was performed in nineteen patients, while 15 patients received conservative treatment. Five patients required an emergency operation. Complications developed in five patients. Four patients were lost due to multiple system injuries. In this study, the injury patterns, complications and mortality of blunt thoracic injuries were discussed.

Adolescent↗