[Clinical features and surgical treatment of thoracic Castleman's disease]

OBJECTIVE

To explore the clinical features and surgical treatment of thoracic Castleman's disease.

METHODS

The clinical symptoms, pathological, laboratory, CT findings and results of surgery in 32 patients with Castleman's disease from June 1996 to November 2008 were evaluated. Among the 32 patients, there were 14 male and 18 female, aged from 16 to 48 years old with a mean age of 34.2 years old. Thirteen cases had symptoms including short of breath, irritable cough, or chest pain, while 14 cases had no symptoms. Mediastinal or hilar tumors were found by CT examination.

RESULTS

Tumor was surgically removed in all the 32 patients except one died with anesthetic accident. Castleman's disease was conformed by pathology. Five cases were diagnosed as with paraneoplastic pemphigus, 3 of them were attacked by bronchiolitis obliterans. All 5 cases were failed by the use of prednisone. The signs of PNP were dissolved after operation, but pulmonary lesions failed to improve. There was no recurrence in all cases.

CONCLUSIONS

PNP and lung abnormalities are the rare and severe complications of thoracic Castleman's disease. Surgical resection of the tumor is the first choice for treatment.

Management of complicated giant thoracic hydatid disease

BACKGROUND

Hydatid disease is a parasitic infestation frequently seen in sheep- and cattle-raising areas of the world, and has been known since the time of Galen and Hippocrates. We retrospectively evaluated patients who underwent surgery in our department due to complicated giant intrathoracic hydatid cysts.

MATERIAL/METHODS

Twenty patients with complicated giant intrathoracic hydatid cysts were operated on between May 2001 and May 2007 in our department. There were 14 male and 6 female patients, with an age range from 10 to 47 years (mean 23.7+/-11.2 years).

RESULTS

The most common symptoms were cough, chest pain, fever, and dyspnea. The most common physical finding was decreased breathing sounds at the affected hemi-thorax. There were signs of cyst perforation of the bronchial space in 14 patients. The cysts were ruptured to the pleural space in 5 patients, with pleural effusion or localized empyema; 4 of them required decortication due to air trapping in the lung. The cyst was found to be intact but infected in 1 patient with cardiac cyst. Cystotomy plus capitonnage was the most frequently used surgical procedure, which was performed in 18 patients, while lobectomy was performed in 1 patient, and left ventriculotomy plus cystotomy plus capitonnage was performed in 1 patient.

CONCLUSIONS

All thoracic hydatid cysts should be operated on as soon as they are diagnosed in order to avoid complications, and surgery should be as conservative as possible. Since preoperative medical therapy can lead to perforation, additional adjuvant medical therapy should only be administered postoperatively to avoid recurrences.

[Hydatid cyst of the chest wall mimicking metastatic colon cancer]

Chest wall hydatidosis, rare even in the endemic countries, represents 0.09 to 0.3 % of all cases of thoracic echinococcosis. The authors report the case of a 76 year-old man presenting a chest wall mass 4 years after surgery for colic carcinoma. The mass presented both hypoechoic and hyperechoic structures in the ultrasound chest echography. Therefore, metastastic colon cancer was suspected. The pathological study of the mass revealed hydatid membranes. Thoracic tomodensitometry supported the diagnosis of costovertebral and soft tissue hydatid cysts. The patient underwent the surgical resection of two rib arches, a transverse apophysis and the neighbouring soft tissue associated with pre- and post-surgical albendazole. No clinical manifestations were noted in the follow-up after 1 year.

Combined reconstruction of complex defects of the chest wall

Defects of the chest wall are often encountered, and good results can be obtained both cosmetically and functionally from their treatment. We treated 13 patients with full thickness chest wall defects. Follow up ranged from 12 days to 19 months. Three had had recurrent breast carcinoma, seven relapse after excision of a sarcoma, two had had lesions of the chest wall after irradiation, and one had a sternal fistula. Local skin, musculocutaneous and free latissimus dorsi and anterolateral thigh flaps were done to cover soft tissue. Fascia lata, polypropylene (Marlex) mesh, and Marlex mesh-methylmethacrylate sandwich prosthesis, were used to stabilise the skeleton in nine patients. Two of the patients died postoperatively, one early. The use of Marlex mesh-methylmethacrylate sandwich prostheses for the stabilisation of the skeleton and local musculocutaneous flaps for covering soft tissues after resection of three or more ribs is effective.

[Miniinvasive video-assisted accesses in thoracic surgery]

Personal 10-year experience of 2412 operations on the thorax is summarized. 1394 (57,8%) of interventions were performed videothoracoscopically. Technical aspects of gross videothoracoscopic operations (552 lung resections and 162 pneumonectomies), indications for the use of the method are discussed. Own results are supplemented with meta-analysis of the literature.

Independent predictors for early and midterm mortality after thoracic surgery

BACKGROUND

The purpose of the present study was to determine independent predictors for early and midterm mortality for the whole context of thoracic surgery.

METHODS

We studied 1453 consecutive patients who underwent thoracic surgery between 2002 and 2005. Operations included lung resections (n = 504), mediastinal (n = 468), pleural and pericardial (n = 226), esophageal (n = 83), chest wall (n = 85), tracheal (n = 50) and other procedures (n = 37). Midterm survival data (mean follow-up 2.0 +/- 1.1 years) were obtained from the National Death Index. Multivariate logistic regression was used to assess in-hospital mortality. Independent predictors for midterm mortality were determined by multivariate Cox regression analysis.

RESULTS

There were 47 (3.2 %) in-hospital and 312 (21.5 %) late deaths. Independent predictors for in-hospital mortality included Zubrod score (OR 2.72, P < 0.001), ASA score (OR 3.42, P < 0.001), pneumonectomy (OR 20.71, P = 0.001) and no history of cerebrovascular events (OR 0.27, P = 0.011). Independent predictors for midterm mortality included age (HR 1.03, P < 0.001), weight loss (HR 1.57, P = 0.005), Zubrod score (HR 1.47, P < 0.001), primary lung cancer (HR 1.98 P < 0.001), intrathoracic extrapulmonary metastases (HR 2.78, P < 0.001), primary chest wall tumor (HR 0.14, P = 0.008), diabetes requiring insulin (HR 1.71, P = 0.017), no preoperative renal failure (HR 0.57, P = 0.004), no comorbidities (HR 0.54, P = 0.009), ASA score (HR 1.69, P < 0.001), postoperative radiation treatment (HR 1.90, P = 0.016), pneumonectomy (HR 2.18, P = 0.040), reoperation for bleeding and/or postoperative transfusion (HR 3.10, P = 0.027) and postoperative pulmonary complications (HR 1.89, P = 0.013).

CONCLUSIONS

We determined independent predictors for in-hospital and midterm mortality for the whole context of thoracic surgery. Zubrod and ASA scores affect both early and midterm mortality.

[Videothoracoscopic removal of ectopic liver]

Authors present a case of an ectopic liver in the chest of a 14 year-old female patient. The lesion was discovered by screening chest X-ray and was consequently removed by videothoracoscopic surgery. A brief literature review was carried out, too.

Ex utero intrapartum treatment (EXIT), a resuscitation option for intra-thoracic foetal pathologies

The ex utero intrapartum treatment (EXIT) procedure is designed to guarantee sufficient oxygenation for a foetus at risk of airway obstruction. This is achieved by improving lung ventilation, usually by establishing an airway during caesarean delivery whilst preserving the foetal-placental circulation temporarily. Indications for the EXIT procedure have extended from its original use in reversing iatrogenic tracheal obstruction in congenital diaphragmatic hernia to naturally occurring upper airway obstructions. We report our experience with a new and rarely mentioned indication for the EXIT procedure, intra-thoracic volume expansions. The elaboration of lowest risk scenarios through balancing risks with alternative options, foetal or neonatal intervention and coordination between professionals from various disciplines are the most important conditions for a successful EXIT procedure. The EXIT procedure requires a caesarean section that specifically differs from the traditional caesarean section during which uterine tone is maintained to minimize maternal bleeding. To guarantee foetal oxygenation during the EXIT procedure, profound uterine relaxation is desired. To gain time with optimal placental oxygenation in order to safely perform an airway intervention in a baby at risk of hypoxia may require deep inhalation anaesthesia and/or tocolytic agents. We review the EXIT procedure and present a case series from the University Hospital of Geneva that contrasts with the common indication for the EXIT procedure usually based on upper airway obstruction by its exclusive indication for intra-thoracic malformations/diseases.

Catamenial and Noncatamenial, Endometriosis-related or Nonendometriosis-related Pneumothorax Referred for Surgery

RATIONALE

Catamenial and endometriosis-related pneumothorax are considered relatively rare entities. Their clinical characteristics and outcome are incompletely known.

OBJECTIVES

To evaluate the frequencies, clinical characteristics, and outcomes of catamenial and endometriosis-related pneumothoraces occurring in women with no underlying lung disease referred for surgical treatment.

METHODS

Clinical files of all the women of reproductive age referred to our center during a 6-year period for surgical treatment of spontaneous pneumothorax were retrospectively reviewed. Catamenial pneumothorax (CP) was defined as recurrent pneumothorax occurring between the day before and within 72 hours after the onset of menses. All histologic slides were reviewed to confirm initial diagnoses.

MEASUREMENTS AND MAIN RESULTS

A total of 114 women underwent video-assisted thoracic surgery; 28 women (24.6%) had CP (right-sided in all but one), and diaphragmatic abnormalities (perforations and/or nodules) were observed in 22 of them. Diaphragmatic abnormalities were seen in 21 of 86 patients with non-CP. Histologic examination found endometriosis, mainly diaphragmatic, in 18 of 28 CPs and 11 of 86 non-CPs. A 6-month antigonadotropic treatment was prescribed postoperatively to women with either CP or endometriosis-related pneumothorax. Mean follow-up was 32.7 (+/-18.5) months. Recurrence rates in CP, non-CP but endometriosis-related, and non-CP non-endometriosis-related pneumothoraces were 32, 27, and 5.3%, respectively.

CONCLUSIONS

Our experience shows that (1) CP and/or endometriosis-related pneumothoraces account for an important percentage of spontaneous pneumothoraces referred for surgery, (2) diaphragmatic abnormalities seem to play a fundamental role in their pathogenesis, and (3) management is difficult because of the high recurrence rate.

A decade of cardiothoracic surgery at a tertiary care hospital in Karachi, Pakistan

OBJECTIVE

The medical records at Aga Khan University were reviewed to analyze the trends, mortality and patients characteristics of cardiothoracic surgeries in the last decade.

METHOD

The medical records of all adult cardiac, thoracic and combined cardiothoracic operations performed during January 1995 to December 2004 at the Aga Khan University Hospital were reviewed. Data were retrieved and analyzed for trends, patient characteristics, and procedure mortality.

RESULTS

From January 1995 - December 2004, 4553 cases were eligible for the study, of which 73% were males and 9.4% were children. Male to female ratio changed from 1.3:1 to 3:1 from childhood to adulthood. Number of patients requiring cardiothoracic intervention increased continuously throughout the period, cardiac operations outnumbering thoracic or combined procedures. Ten-year average annual mortality remained 4.8% with slight variation per annum. Age distribution of cardiac surgery patients remained the same, however, constantly increasing number of over-70-year olds was observed. Mortality for isolated CABG, isolated valve and CABG with valve remained 1.9%, 4.3% and 18.3% respectively.

CONCLUSION

Trends of cardiothoracic procedures appear similar to those in the developed countries, so are the mortality figures.

Thoracic surgical operations performed under local anesthesia and sedation for diagnosis and treatment

Generally, the operative procedures for the diagnosis or treatment of mediastinal, intrathoracic and/or chest wall lesions requiring rib resection are performed under general anesthesia. Although evidence suggests that thoracoscopy can be performed under local anesthesia, no report has indicated that some major thoracic procedures can be accomplished without general anesthesia. In our study, we advocate that certain surgical procedures could be performed under local anesthesia with a performance similar to that of general anesthesia. Thirty patients underwent thoracic procedures with local anesthesia and sedation for diagnosis and treatment. Seventeen of the patients were men, and the mean age of the patients was 49.6 years (range 16 to 71 years). There were 13 diagnostic procedures, and 17 procedures were for treatment purposes. The operative procedures performed using only local anesthesia were mini-thoracotomy (n = 9), mediastinotomy (n = 4), revision of a full-thickness posterolateral thoracic incision (n = 7), resection of the chondroma (n = 4), Eloesser flap (n = 1), metastasectomy of the chest wall (n = 3), empyectomy (n = 1), and video-assisted thoracoscopy (n = 2). Severity of pain was evaluated by VAS. There were no oral or intravenous analgesic requirements in the early postoperative period. No complications attributable to the procedure were observed. Thoracic surgical procedures for diagnosis and treatment performed under local anesthesia are simple, effective, economical and comfortable for the patient.

Predictors of general complications after video-assisted thoracoscopic surgical procedures

BACKGROUND

The video-assisted thoracoscopic approach has become the preferred method for many procedures due to the reduced trauma, complication rate and morbidity. The aim of this study was a risk evaluation of patients undergoing video-assisted thoracoscopic surgery (VATS) procedures.

METHODS

Between 1991 and 2004, 1,008 patients were included in this single-center retrospective analysis. Risk assessment was performed using univariate and multivariate analysis.

RESULTS

Multivariate analysis revealed that patient age (p = 0.003), the duration of the VATS procedure (p = 0.008), redo-VATS (p < 0.001) and conversion to open thoracotomy (p < 0.001) correlated significantly with the incidence of complications. Patients with immune deficiency following organ transplantation had the highest complication rate at 31.7%, which was significantly higher than for patients with either benign disease (p = 0.010) or malignant disease (p = 0.019).

CONCLUSIONS

VATS is a safe procedure, but extra caution is recommended for patients with a higher risk profile (age, redo-VATS, immune deficiency).

[Clinical characteristics of Bochdalek hernia in neonates and infants]

OBJECTIVE

To summarize the clinical characteristics, diagnosis and treatment of Bochdalek hernia in neonates and infants.

METHODS

The data of 15 neonates and 10 infants with Bochdalek hernia,undergoing the normal diagnosis and surgical repair from August 1983 to June 2004, were retrospectively reviewed. Location was left in 22 cases and right in 3 cases. Twenty-four cases were treated by operation and 1 case died of respiratory failure before operation.

RESULTS

Before April 1998, 7 of 8 (5 neonates, 3 infants) cases of Bochdalek hernia stayed healthy and respiratory symptom-free 1 year after operation; they were followed up 1 year and 3 months to 11 years. One premature neonate with Bochdalek hernia died of respiratory failure before operation, and his lung volume was found to be dysplasia. From April 1998 to June 2004, 15 (8 neonates,7 infants) of 17 (10 neonates, 7 infants)cases of Bochdalek hernia survived postoperatively, while 2 neonates died of respiratory failure.

CONCLUSION

The earlier dyspnoea of neonates of Bochdalek hernia occur, the worse their healthy status appear. The standard and timely surgical repairs could improve the curative ratio. Whether the operation was suspended depended on the healthy states of babies.

Huge extrapleural hematoma in an anticoagulated patient

We report an unusual case of huge extrapleural hematoma in an anticoagulated patient with no apparent traumatic episode. An extrapleural hematoma (EH) was successfully treated by video-assisted thoracic surgery (VATS). If an EH is large enough to cause ventilatory or circulatory disturbances, VATS may be the first option for the management of EH. Otherwise limited thoracotomy should be considered.

L'endométriose extragénitale

Parietal, appendiceal, pleuropulmonary and diaphragmatic endometriosis represent 5% of endometriosis cases. Diagnosis and management of these extra-genital localisations are described according to the literature. Parietal endometriosis usually requires large resection of the tumor. Appendiceal endometriosis is frequently observed in cases of digestive endometriosis. Induration or rigidity of the appendix due to the presence of deep infiltrating endometriosis justifies appendicectomy. Thoracic and diaphragmatic endometriosis is characterized by the presence of typical symptoms during the perimenstrual periode. Medical treatment obtaining therapeutic amenorrhea is firstly administered and surgery is indicated in cases of symptoms recurrence.

Castleman's disease arising from the chest wall

An 18-year-old man was referred to our hospital because of an abnormality on chest radiography. Computed tomography showed a sharply defined, 5 x 2 x 3 cm, densely enhanced mass in the left side of the chest wall. We performed tumor resection under video-assisted thoracoscopy, with minimal bleeding. Histologically, the tumor was shown to be Castleman's disease. This is the eleventh case of Castleman's disease arising from the chest wall reported over the last 20 years.

Thoracic myelopathy in Japan: epidemiological retrospective study in Miyagi Prefecture during 15 years

Thoracic myelopathy is defined as spinal cord compression in the thoracic region, leading to sensory and motor dysfunctions in the trunk and lower extremities, and can be caused by various degenerative processes of the spine. Thoracic myelopathy is rare, and there are many unsolved problems including its epidemiological and clinical features. We have established a registration system of spinal surgeries, which covered almost all surgeries in Miyagi Prefecture, and enrolled the data of 265 patients with thoracic myelopathy from 1988 to 2002. The annual rate of surgery gradually increased and averaged 0.9 per 100,000 inhabitants, which was less than 1/10 of that for cervical myelopathy. About 20 patients with thoracic myelopathy are operated on in Miyagi Prefecture each year. It frequently develops in middle-aged males. About half of the cases were caused by ossification of the ligamentum flavum, followed by ossification of the posterior longitudinal ligament, intervertebral disc herniation and posterior spur. Patients usually noticed numbness or pain in the legs and the preoperative duration was long, averaging 2 years. Its symptomatic similarities to lumbar disorders might cause difficulty in making a correct diagnosis. Since thoracic myelopathy can markedly restrict the activities of daily life, even general physicians should recognize this entity.

Anterior thoracic wall traumatic lymphocele: a case report

Traumatic lymphoceles are usually the result of surgical injuries or blunt trauma. Although usually described in the pelvis after radical pelvic node dissection or kidney transplantation, traumatic lymphoceles are rare. Diagnosis is based on CT scan and confirmed by fine needle aspiration with biochemical analysis. Treatment modalities are not standardized and different techniques have been described. We report herein a case of anterior thoracic wall lymphocele due to blunt trauma treated in our department.

Intrathoracic testicular ectopia in congenital diaphragmatic hernia

Congenital diaphragmatic hernia (CDH) is a defect in the diaphragm through which intra-abdominal and retroperitoneal organs may pass. However, the presence of the testis in the thoracic cavity is rare. Here, we describe a case of left-sided Bochdalek CDH with herniation of the left testis through the defect into the thorax, which was managed successfully by primary orchiopexy.

Chest wall/diaphragmatic complications

This article discusses the prevention and management of chest wall and diaphragmatic complications after extrapleural pneumonectomy, the prevention of thoracoplasty scoliosis, the complications after chest wall resection, and the presentation, prevention, and management of chest wall hernia. Appropriate preoperative assessment and patient selection, meticulous attention to detail intraoperatively, and diligent postoperative observation and care are needed to prevent these events.

[Thoracic surgery in children--common diseases and their therapy]

In the day life in a thoracic surgery department interventions in childage are more or less seldom. The skill of the surgical and anesthesiological team is strictly related to the outcome of the patient. Beneath benign tumors of the lung and mediastinum are inflammatory diseases first of all pleuraempyema in the focus of interest. VATS is an increasing point of diagnostic and therapies.

Multifocal mesenchymal hamartoma of the chest wall

Chest wall hamartomas are extremely rare. Frequently mesenchymal hamartomas are presented as a single mass and contain some primitive mesenchymal elements such as chondroid and trabecular bone structures. A 60-year-old man presented to hospital with chest pain. Thirteen years earlier, his CXR and thoracic CT showed three masses on the right and two masses on the left, but he had not received any treatment thereafter. His CT showed the same masses present 13 years earlier, but they were bigger and right thoracotomy was undertaken. At thoracotomy, two sections of the mass in the right posterior mediastinum and one section of the mass in the right apex were excised. They had an occasional bloody appearance and contained small cystic areas, and some areas were extremely hard. Microscopic examination showed that the lesions consisted of mature adipose tissue, a large number of veins of different diameters and collagen tissue. Besides, primitive mesenchymal elements, lymphoid cell accumulations and trabecular bone structures were seen focally. Bilateral chest wall hamartomas are extremely rare and may be confused with malignancy.

Congenital intrathoracic kidney with right Bochdalek defect

Intrathoracic kidney is a rare congenital anomaly. Since most reported cases are asymptomatic, it is extremely rare for this ectopia to be diagnosed in the neonatal period. We report a male infant with right intrathoracic kidney associated with Bochdalek defect. Chest X-ray demonstrated a right posterior mediastinal mass and intestinal gas in the right lung field. Contrast-enhanced CT and intravenous urography led to a diagnosis of intrathoracic kidney. Due to the presence of Bochdalek defect, the intrathoracic kidney was reduced into the abdominal cavity at the time of diaphragmatic repair. The intrathoracic kidney with attached adrenal gland was located at the level of the carina and was covered with protruded retroperitoneum. The kidney was thought to have been pushed this high by the small intestine and left lobe of the liver, which had also herniated through the defect. Postoperative hemodynamics and renal function were normal.

Muscle sparing thoracotomy in pediatric age: a comparative study with standard posterolateral thoracotomy

Alternative approaches to the standard posterolateral incision for thoracotomy have been developed to minimize its postoperative pain and wound related side effects. Muscle-sparing (MS) thoracotomy has been a well-known substitution to the standard posterolateral thoracotomy for this purpose; however it has not been studied in the pediatric age group in detail. We studied retrospectively the patients with thoracotomy for non-cardiac, thoracic surgical procedures. Group 1 included the patients with standard posterolateral thoracotomy for the surgery. The patients with MS thoracotomy composed group 2. The related data were collected retrospectively. The early postoperative morbidities (time requiring for regaining shoulder girdle movement, extubation, intensive care unit stay, and hospital stay) and late musculoskeletal anomalies (scoliosis, elevation of the shoulder, winged scapula, asymmetry of the nipples) were compared between groups. A total of 90 patients were included in the study. Group 1 constituted 50 patients with an average age of 4.24 +/- 2.91 years. Group 2 included 40 patients with an average age of 4.20 +/- 2.92 years. Comparison of the demographics and the baseline characteristics of the patients were not different between groups. In comparison of operative characteristics, there was lesser morbidity in group 2 as re-exploration for bleeding, wound infection, wound healing and fewer intensive care unit and hospital stay days. Late follow-up revealed a significant increase in musculoskeletal deformities in group 1. We conclude that muscle-sparing incision should be preferred to the standard posterolateral thoracotomy in pediatric age.

[Video-assisted thoracic surgery: clinical experience among 1264 patients]

OBJECTIVE

To summarize the clinical experience in video-assisted thoracic surgery (VATS).

METHODS

From December 1993 to December 2005 1264 patients, 894 males and 370 females, aged 38.9 +/- 12.0, underwent VATS, including bullectomy in 622 cases, resection of mediastinal tumor or cyst in 119 cases, resection of esophageal diseases in 107 cases, lobectomy or wedge-shaped lung resection in 215 cases, lung volume reduction surgery (LVRS) in 17 cases, treatment of thoracic injury in 28 cases, treatment of other thoracic diseases in 72 cases, and biopsy in 84 cases. For the resection of esophageal carcinoma VATS was conducted via the right approach, the esophagus was dissociated, the lymph nodes were resected, upper-abdominal incision was made, the stomach was dissociated and drawn up to the neck region, a cervical incision was made to anastomose the stomach and the residue of esophagus.

RESULTS

Operation was completed by VATS successfully in 1230 patients, and 34 cases were converted to traditional thoracotomy because of thoracic adhesion or to radically treat the malignant tumors. Major complications occurred in 45 cases (3.56%), including air-leak lasting more than 7 days in 30 cases, post-operative bleeding in 4 cases (3 of which received VATS once more for hemostasis and the other underwent thoracotomy), hydrothorax or pneumothorax in 3 cases that underwent water-closed drainage, esophageal mucous rupture in 4 cases with achalasia and one case with leiomyoma, all of which underwent repair immediately, infection of pleural cavity in one case after the resection of esophageal diverticulum, and pneumonia in one case after LVRS. One patient with spontaneous pneumothorax and respiratory failure died 5 days after the bullectomy. Spontaneous pneumothorax occurred in 10 patients 2 months to 2 years after VATS 3 of which underwent bullectomy and pleurodesis by VATS once more.

CONCLUSION

Spontaneous pneumothorax and some benign thoracic diseases are the major indications of VATS; however, great care should be expended to decide to treat malignant diseases by VATS. It is very important to train the surgeons who are to practice VATS. The practice of VATS should be individualized.

Catamenial Bernard-Horner’s Syndrome Related to Thoracic Endometriosis

We describe the case of a young woman with a recurrent right Bernard-Horner's syndrome associated with the onset of intermittent supraclavicular mass. Surgical excision of the mass revealed the endometrial pattern of the tumor and the close relationship between Bernard-Horner's syndrome and thoracic endometriosis. No other case of this syndrome has been reported in the literature.

Surgically removed thoracolithiasis: report of two cases

Thoracolithiasis is a rare condition with only 12 cases of surgically removed nodules reported in the literature. We report 2 additional cases. Case 1: A 19-year-old male admitted with an abnormal shadow on a chest X-ray. Computed tomography (CT) revealed a nodule in the right lower lung lobe. The material extirpated by thoracoscopy was milky white, glossy, and 1.6 cm in diameter. Histopathologically, it consisted of fatty necrotic tissue covered with hyalinized fibrous tissue. Case 2: A 78-year-old female, with a past history of breast cancer, admitted with an abnormal shadow on chest X-ray. CT revealed a nodule in the left lung S(1+2) segment, of which transbronchial biopsy findings indicated primary lung adenocarcinoma. Exploratory thoracoscopy incidentally revealed some pearly material, 0.4 cm in diameter, in the thoracic cavity. They were extirpated during left upper lobectomy for lung cancer; all of them demonstrated concentric hyalinized fibrous tissue. Thoracic surgeons should consider this condition in the differential diagnosis of a peripheral pulmonary nodule.

[Catamenial pneumothorax]

Catamenial pneumothorax (CP) is a specific type of secondary spontaneous pneumothorax. It is characterized by a temporal relationship with menses. CP is considered to be the most frequent symptom of thoracic endometriosis. It occurs mainly in women above 30 years of age and is typically right sided. The authors reviewed the current literature on this entity. The hypotheses on its pathogenesis and the diagnostic possibilities and therapeutic options are discussed.

Video assisted thoracoscopic surgery at the Queen Elizabeth Hospital Barbados

Video assisted thoracoscopic surgery (VATS) is now an established technique for diagnostic and therapeutic intervention in patients with thoracic pathology at the Queen Elizabeth Hospital (QEH). This article reviews the experience with 50 patients over the period May 1996 to February 2003, looking at various factors and outcomes in an attempt to ascertain the viability of this procedure at this institution. It serves as a follow-up article to the publication of the initial experience in 1999 (1). There were 24 males and 26 females included in the study. Video assisted thoracoscopic surgery was used for diagnosis in 27 cases (54%), therapeutic indication in 17 cases (34%) and as both a diagnostic and therapeutic modality in six cases (12%). In 92% of cases, the operations were completed thoracoscopically with a conversion rate of 8%. The morbidity and mortality rates were 18% and 2% respectively. Video assisted thoracoscopic surgery is an effective tool for the treatment and investigation of selected thoracic pathology at the QEH with complications and mortality rates comparable to other institutions (2, 3).

[Tuberculous abscess in the chest wall; report of a case]

A 72-year-old woman was admitted to our hospital with left chest pain. Chest computed tomography (CT) revealed an abscess in the left lateral chest wall. Bacterial examination of needle aspiration biopsy specimen from the chest wall abscess disclosed positive acid-fast bacilli. The size of chest wall abscess increased after initiation of antituberculous therapy with isoniazid, rifampicin, ethambutol hydrochloride and pyrazinamide, and therefore abscess drainage was subsequently performed. The lesion was resected after the abscess had diminished in size.

Anterior surgical approaches to the thoracic outlet

OBJECTIVES

The anatomy of the thoracic outlet is complex, and the optimum surgical approach to pathologic disease at this location is controversial. Although the Dartevelle approach to the apex seems to be a safer and more direct approach, this technique has not been widely adopted in the United States. We have used this approach for pathologic disease at the thoracic outlet and modified it. Our experience is described in this article.

METHODS

A retrospective review was performed on all patients who underwent an anterior approach between December 1997 and May 2003.

RESULTS

There were 42 patients who underwent anterior approaches to pathologic disease at the level of the outlet. Diagnosis included apical non-small cell lung cancers (20 patients), osteosarcoma (2 patients), spinal cord compression (5 patients), solitary metastasis (4 patients), and benign lesions (11 patients). There were 22 female and 20 male patients with ages ranging from 26 to 82 years (mean age, 54.6 years). There were 25 complications in 14 patients and 1 in-hospital death. A transmanubrial approach was used in 14 patients, the standard Dartevelle technique was used in 8 patients, and a transclavicular approach with reapproximation of the clavicle was used in 20 patients. Reapproximation failed in 5 patients (3/3 patients who underwent fixation with mini-plates and 2/17 patients with sternal wires).

CONCLUSIONS

The anterior approach is a useful adjunct to a thoracic surgeon's armamentarium. When a transclavicular approach is optimal, division and reapproximation of the clavicle are feasible. In our experience, reapproximation with wires is superior to plates and screws.

Surgical management of pulmonary and gastrointestinal complications in children with cystic fibrosis

PURPOSE OF REVIEW

Cystic fibrosis is a common disorder, affecting as many as 1:2500 Caucasian live births. Despite improved medical management, disease-specific complications are common and are responsible for substantial morbidity and ultimately mortality. Both pulmonary and gastrointestinal complications of cystic fibrosis are well known; however, the complications requiring surgical intervention in the pediatric population are infrequent. We provide a detailed review of the cystic fibrosis-associated pulmonary and gastrointestinal complications and potential surgical options for management in children with cystic fibrosis.

RECENT FINDINGS

Recent operative approaches are described that include application of minimally invasive surgical techniques primarily for intrathoracic disease. Novel medical therapies are also presented. Finally an attempt is made to put in perspective those surgical care advances that have had a benefit on disease outcomes.

SUMMARY

This report will provide the physician caring for the child with cystic fibrosis an understanding of those disease complications that will require surgical consultation and potential operative intervention.

Current concepts in surgical management of pediatric lung and chest wall diseases

PURPOSE OF REVIEW

The management of pediatric lung and chest wall diseases has changed dramatically in the last decade because of the application of minimally invasive surgical techniques. This review will try to highlight some of the more significant recent contributions.

RECENT FINDINGS

Most of the papers quoted will show that the application of minimally invasive surgery to the treatment of common problems such as empyema, pneumothorax, and lung biopsy has significantly altered our treatment algorithms, because of decreased morbidity and improved outcomes compared to standard surgical or medical treatment plans. This has also been true for pediatric chest wall deformities, which previously were treated in only the most severe cases and thought to be mostly cosmetic in nature. More recent reports now show statistically significant improvements in cardio-pulmonary physiology as well as quality of life.

SUMMARY

The application of less invasive surgical procedures for lung and chest wall diseases has warranted earlier intervention, with better outcomes, and less morbidity than previously used techniques. A clear understanding of these techniques and their benefits is important for the referring and treating physician as previously used treatment protocols may no longer provide the best patient care.

Nueva técnica quirúrgica para glándulas paratiroides intratorácicas: la videotoracoscopia con detección de Tc-MIBI intraoperatoria

Ectopic mediastinal parathyroid glands are uncommon (1-11% of all cases of hyperparathyroidism). Median sternotomy used to be performed to resect them, with large and painful incisions that prolonged the length of hospital stay. Current imaging techniques (thoracic computed tomography and Tc-mibi scan) can accurately locate the ectopic glands, allowing minimally invasive exploration. We report a new surgical technique: video-assisted thoracoscopic resection associated with intraoperative Tc-mibi scintigraphy for ectopic mediastinal parathyroid glands. This technique allows minimally invasive access and reduces complications and length of hospital stay. Therefore we believe that video-assisted thoracoscopy could become the technique of choice in patients with high surgical risk and a fifth ectopic parathyroid gland. We report the case of a 49-year-old man in whom surgery was successful.

Necrobiotic xanthogranuloma of the chest wall

Necrobiotic xanthogranuloma is a rare disease that usually presents with indurated yellow red nodules or plaques in the dermis or subdermal tissues. The pathogenesis of this disease is unknown and the limited number of cases has made long-term studies difficult. We report the case of a 61-year-old woman seen in our office for a 5 x 5-cm lesion of her chest wall. Biopsies established a diagnosis of necrobiotic xanthogranuloma. The patient received 4 months of intralesional steroid injections without change in the lesion. The patient was also treated with colchicine for several months without improvement. Therefore, the lesion was surgically excised and the area was reconstructed with local advancement skin flaps. The patient has been followed for 2 years with no evidence of recurrence.