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

A case of recurrent tuberculous abscess in the chest wall which was successfully treated by resection of the rib and transposition with a latissimus dorsi muscle flap is reported. A 70-year-old man was admitted to the hospital for the purpose of receiving tuberculostatic treatment after an operation for tuberculous abscess in the chest wall at another hospital. When he first visited the another hospital, he had complained of a left chest wall tumor and Mycobacterium tuberculosis was isolated from the pus. After admission to the hospital, tuberculous abscess recurrenced in the left chest wall 2 months after the operation. We performed resection of the abscess, 5th and 6th ribs, as well as transposition of the latissimus dorsi muscle flap. There have been no signs of recurrence and is followed in the clinic, as of 4 months after the operation. We think that resection of the abscess, ribs, and, transposition of the muscle flap are useful methods for tuberculous abscess in the chest wall.

Ureteropelvic junction obstruction in a thoracic kidney treated by dismembered pyeloplasty

Ectopic positioning of the kidney is a relatively common event, with the thoracic location of the ectopic kidney the most unusual. At least 140 cases of thoracic kidney have been described, with no consistent anomalies reported in association with the superior location. The vast majority of patients with thoracic kidney are asymptomatic, with the problem discovered incidentally. We report the first documented case of a thoracic kidney presenting with flank pain and demonstrating ureteropelvic junction obstruction on nuclear scintigraphy treated by open dismembered pyeloplasty through a supra-11th rib incision.

Chest wall hamartoma. Report of two cases with secondary aneurysmal bone cysts

Chest wall hamartoma is a rare non-neoplastic benign lesion occurring in the neonatal period with particular clinical, radiological and pathological features. Histologically, it is composed of a mixture of bone trabeculae with spindle-cell stroma, chondroblast-like cells, and mature and immature hyaline cartilage. Aneurysmal bone cyst is a benign lesion that may arise secondary to several bone processes, such as giant cell tumor, chondrosarcoma, non-ossifying fibroma or osteosarcoma. We present two new cases of chest wall hamartoma with secondary aneurysmatic bone cyst formation studied with histological and immunocytochemical methods.

[Hydatid cyst of thoracic soft tissues]

Hydatid cysts are uncommon in thoracic soft tissue. We report a case of hydatid cyst which had developed within the lattissimus dorsi presenting as a left parietal scapular mass diagnosed by ultrasound and CT scan, which remains the preferred primary examination for the investigation of masses of this type. We discuss the various possible clinical and paraclinical contexts and recommend total pericystectomy of a closed cyst as the best treatment for this kind of cyst.

Surgical treatment of tuberculous cold abscess of the chest wall

The incidence of tuberculosis (Tbc) infection is high in some parts of the world and tuberculous cold abscess of the chest wall (CACW) often fails to respond to medical treatment. Medical records of 178 patients who underwent surgical treatment of chest wall abscesses from July 1970 to Sept. 2000 were reviewed and 89 patients who were pathologically confirmed as Tbc cold abscess cases were included in this study. Their ages ranged from 9 to 71 years (mean 33.3 years) and the male to female ratio was 1.2:1 (49 male, 40 female). The symptoms were palpable chest wall mass, pain and pus discharge, and three patients had multiple lesions. Twenty-five patients (28%) underwent excision of chest wall abscesses and 64 patients (72%) underwent chest wall and rib resection. Tbc medication was given preoperatively in 39 patients for an average of 6.3 months and all patients were given Tbc medication postoperatively for an average of 12 months. Postoperative complications were bleeding, pus discharge, empyema, pleural effusion, wound dehiscence, subcutaneous emphysema and activation of pulmonary Tbc. The disease recurred in 7 patients (7.8%) and these 7 patients all underwent a second operation. We recommend preoperative Tbc medication and complete resection of chest wall abscesses including any suspicious ribs. Postoperative Tbc medication for a minimum of 12 months is essential to decrease the risk of a relapse.

Paraparesis after excision of intrathoracic meningoceles in a patient with neurofibromatosis

Intrathoracic meningocele associated with neurofibromatosis is a rarity. We treated a 16-year-old boy with neurofibromatosis, marked kyphoscoliosis, and two right-sided intrathoracic meningoceles. Because his chief complaints of cough and chest pain were thought to be caused by the meningoceles, resection of these lesions was performed prior to correction of the spinal deformity. On the day after the resection, complete paraplegia developed, followed by recovery to paraparesis. Decompressive lumbar puncture was performed, but intraspinal pressure was normal. Postoperative spinal cord damage and consequent paresis may have resulted from a loss of pressure buffering by the meningocele, which rendered the cord vulnerable to injury. The possibility of a similar unusual complication should be borne in mind when treating patients with intrathoracic meningocele associated with neurofibromatosis.

Meconium thorax: A case of Bochdalek hernia and cecal perforation in a neonate with Job's syndrome

Meconium peritonitis most often is associated with congenital intestinal obstruction and meconium ileus. Uncommonly, other etiologies are identified. Hyperimmunoglobulin E syndrome (Job's syndrome) is a rare genetic disorder that is characterized by recurrent staphylococcal respiratory and skin infections in addition to elevated serum IgE levels. There have been 2 previously reported cases of intestinal complications associated with Job's syndrome. The current case is the third such case and is the first report of meconium peritonitis in a patient with hyperimmunoglobulin E syndrome. The patient presented with a meconium thorax as a result of a concurrent congenital diaphragmatic hernia.

[Tele-surgery of thoracic sympathectomy]

Experience of surgical treatment of Raynaud's disease with application of thoracoscopic sympathectomy (TSSE) method using telesurgical technique was analyzed. Operative intervention was performed in 17 patients. Stable positive result was observed in all the patients for the period of 2 years and more. Regarding the intervention traumaticity, efficacy of treatment in immediate and late postoperative period, the patients quality of life, the duration of stay in hospital and the value of treatment, the TSSE results, performed with telesurgical technique application, were significantly better than the results of thoracotomic sympathectomy. Peculiarities of anesthesiologic support and predominance of application of monopulmonary artificial ventilation of lungs during performance of thoracic sympathectomy were noted.

[Combined surgery for cardiovascular disease and general thoracic lesions]

Surgical management of patients with concomitant critical cardiovascular disease and resectable general thoracic lesions is controversial. During a 16-year period (1985 to 2001), 15 patients underwent combined cardiovascular and general thoracic operations, of the 2,459 patients who underwent a cardiovascular operation requiring cardiopulmonary bypass at our institution. Patients had cardiovascular symptoms only and the general thoracic lesions were incidentally found by preoperative chest roentgenograms and/or computed tomography. Because of the cardiovascular disease, a pathological diagnosis was precluded before surgery. All except one descending thoracic aortic operation underwent concurrent pulmonary resection after neutralization of protamine following cardiovascular surgery requiring extracorporeal circulation. Lung pathology consisted of pulmonary bullae (n = 7), primary lung cancer (n = 4), benign lung tumor (n = 2), metastatic lung cancer (n = 1), and thymic cyst (n = 1). The pulmonary operations include bullectomy (n = 7), wedge resection (n = 6), lobectomy (n = 3), and removal of a thymic cyst (n = 1) including 2 staged procedures. The final diagnoses in 4 lung cancer cases were T1. N0M0, stage IA (n = 3) and T2N2M0, stage IIIA (n = 1). All malignancies including metastatic lung cancer, were able to be completely resected. The mean intraoperative bleeding volume for the cases was 997 +/- 221 ml, while mean duration of surgery was 382 +/- 31 minutes. Except for 2 cases required long term ventilatory support, the mean durations of tracheal intubation and ICU stay were 2.2 +/- 0.2 and 3.8 +/- 1.0 days respectively. Except for 1 surgical death, mean survival duration and 5-year survival rate were 59.7 +/- 12.5 (5-177) months and 66.3% respectively. These findings suggest that combined pulmonary resection with cardiovascular surgery is safe and offers a favorable prognosis to a selected group of patients.

Left-sided congenital diaphragmatic hernia associated with intrathoracic ectopic liver lobule

A case of intrathoracic ectopia of the left lobe lateral segment of the liver in a patient with left-sided diaphragmatic hernia is described. The ectopic liver part was found in the left hemithorax during excision of the diaphragmatic hernia sac, but it was not the content of the sac. The ectopic liver part has not been described previously in the left hemithorax and is actually the primary abnormality. The diaphragmatic hernia is merely a secondary development through this potential gap on the diaphragm where the pedicle of the ectopic liver lobule passes.

Anesthetic implications of thoracic endometriosis

Endometriosis occurs in 5% to 10% of women of childbearing age and involves the proliferation of endometrial tissue outside the uterine cavity. Thoracic endometriosis is the most frequent extrapelvic manifestation of endometriosis, numbering some 100 reported cases. It may include spontaneous pneumothorax, hemoptysis, chest pain, bronchiectasis, pneumomediastinum, or mediastinal bleeding. Because the tissue is hormonally responsive, all of these manifestations are related to the menstrual cycle (catamenial) and are likeliest to occur during menses. We report the successful anesthetic management of a patient with thoracic endometriosis and recurring catamenial pneumothorax who presented for elective pelvic surgery.

Relation of the static compliance curve and positive end-expiratory pressure to oxygenation during one-lung ventilation

BACKGROUND

Positive end-expiratory pressure (PEEP) is commonly applied to the ventilated lung to try to improve oxygenation during one-lung ventilation but is an unreliable therapy and occasionally causes arterial oxygen partial pressure (PaO(2)) to decrease further. The current study examined whether the effects of PEEP on oxygenation depend on the static compliance curve of the lung to which it is applied.

METHODS

Forty-two adults undergoing thoracic surgery were studied during stable, open-chest, one-lung ventilation. Arterial blood gases were measured during two-lung ventilation and one-lung ventilation before, during, and after the application of 5 cm H(2)O PEEP to the ventilated lung. The plateau end-expiratory pressure and static compliance curve of the ventilated lung were measured with and without applied PEEP, and the lower inflection point was determined from the compliance curve.

RESULTS

Mean (+/- SD) PaO(2) values, with a fraction of inspired oxygen of 1.0, were not different during one-lung ventilation before (192 +/- 91 mmHg), during (190 +/- 90), or after ( 205 +/- 79) the addition of 5 cm H(2)O PEEP. The mean plateau end-expiratory pressure increased from 4.2 to 6.8 cm H(2)O with the application of 5 cm H(2)O PEEP and decreased to 4.5 cm H(2)O when 5 cm H(2)O PEEP was removed. Six patients showed a clinically useful (> 20%) increase in PaO(2) with 5 cm H(2)O PEEP, and nine patients had a greater than 20% decrease in PaO(2). The change in PaO(2) with the application of 5 cm H(2)O PEEP correlated in an inverse fashion with the change in the gradient between the end-expiratory pressure and the pressure at the lower inflection point (r = 0.76). The subgroup of patients with a PaO(2) during two-lung ventilation that was less than the mean (365 mmHg) and an end-expiratory pressure during one-lung ventilation without applied PEEP less than the mean were more likely to have an increase in PaO(2) when 5 cm H(2)O PEEP was applied.

CONCLUSIONS

The effects of the application of external 5 cm H(2)O PEEP on oxygenation during one-lung ventilation correspond to individual changes in the relation between the plateau end-expiratory pressure and the inflection point of the static compliance curve. When the application of PEEP causes the end-expiratory pressure to increase from a low level toward the inflection point, oxygenation is likely to improve. Conversely, if the addition of PEEP causes an increased inflation of the ventilated lung that raises the equilibrium end-expiratory pressure beyond the inflection point, oxygenation is likely to deteriorate.

Role of thoracic surgery in patients suffering from Acquired Immune Deficiency Syndrome

BACKGROUND AND PURPOSE

To study the role of thoracic surgery in patients suffering from Acquired Immune Deficiency Syndrome (AIDS) in a South Bronx community with a high incidence of the disease.

METHODS

A retrospective analysis of medical records of patients who underwent thoracic surgery at Bronx-Lebanon hospital, New York, over a three year period between 1996-1998.

RESULTS

The thoracic surgeons at Bronx-Lebanon Hospital in New York operated upon a total of 210 patients. Of these, 39 were operated upon for AIDS-related illnesses, comprising 17% of the operative workload. The indications of surgery in these patients were variable, ranging from infections to tumours. Fifteen patients were operated on for pericardial effusion. Ten were operated on for empyema, which had failed to resolve with thoracostomy alone and necessitated decortication. Tumours also formed a significant portion of the surgical workload. Three patients had Kaposi's sarcoma of the lung and three had a primary lymphoma in the lung. The mortality rate was high (46%).

CONCLUSION

The data suggest that surgical intervention in AIDS-related chest diseases is unable to alter the course of the disease. Earlier detection and intervention of these complications may improve outcome in some patients.

Unusual sites (thorax and umbilical hernial sac) of endometriosis

Extra-pelvic endometriosis in the thorax or umbilical hernia is rare. We report a case of thoracic endometriosis presenting with isolated chest pain and a case of endometriosis in an umbilical hernial sac mimicking incarceration. The clinical course and management of the patients and a literature review of these two unusual sites of endometriosis are discussed.

The diagnosis and treatment of a thoracic abscess in an alpaca

A 6-month-old alpaca presented for lethargy, failure to thrive and leucocytosis. Diagnostic procedures, including thoracic ultrasound, radiographs and a computed tomography scan, were used to document a thoracic mass. Based on appearance and ultrasound-guided aspiration of purulent material, the mass was determined to be a large abscess. The abscess was treated with surgical drainage and long-term antibiotic therapy. The origin of this thoracic abscess was felt to be the caudal mediastinum, secondary to bacterial seeding of the caudal mediastinal lymph nodes. Although an aetiological agent was not definitively determined, the most likely was Actinomyces spp or Arcanobacterium pyogenes. The alpaca made a complete recovery following treatment.

Calcification of the thoracic ligamentum flavum: a rare cause of myelopathy

Compressive myelopathy secondary to ossification or calcification of the ligamentum flavum is a rare entity. Clinical features and magnetic resonance imaging findings of a patient of dorsal cord compression who improved remarkably with surgery are reported.

A single-trocar technique for minimally-invasive surgery of the chest

BACKGROUND

In thoracic surgery, the classic thoracoscope is used to perform simple maneuvers in the chest. We have devised a minimally invasive technique that requires only a single trocar. This technique is used in our department to diagnose and treat a wide range of thoracic pathologies.

METHODS

Between October 1998 and August 1999, 37 patients underwent surgery prospectively for a thoracic disease through a single trocar. There were 19 men and 18 women with a mean age of 60 years (range, 40-85). The trocar was flexible or soft and had a diameter of 15-20 mm. A 2-cm skin incision was made in the planned intercostal space. The chest drain was always inserted under video control.

RESULTS

The mean operative time was 53 +/- 5 min. One patient developed intraoperative bleeding that required intubation and a 5-cm mini-thoracotomy. In one patient with stage II empyema, it was necessary to insert another trocar. Chest tubes were removed after 77.7 +/- 7 h. Hospital stay was 4 +/- 1 days (range, 2-14). Histologic examination revealed malignant disease in 26 cases and benign disease in 11. Two patients (5.4%) developed wound infections. None of the patients had port site metastasis. There were no hospital deaths.

CONCLUSION

Because of its simplicity, we recommend the use of this mini-invasive technique in place of the classic thoracoscope or video-mediastinoscope.

Video-assisted thoracoscopy

Thoracoscopy is a minimally invasive operative endoscopic procedure designed for visual inspection of the thoracic cavity. The use of small, highly maneuverable, rigid telescopes allows visualization beyond what is possible by standard operative techniques. The use of a small video camera attached to a standard rigid telescope allows the operator and assistants to view a simultaneous, enlarged, and clear image. This article focuses on the basic diagnostic and surgical techniques used in veterinary video-assisted thoracoscopy.

Ectopic intrathoracic liver

Accessory hepatic tissue, unlike accessory splenic and pancreatic tissue, is rare and has a limited and almost exclusively sub diaphragmatic distribution. Fewer than ten cases of intrathoracic ectopic liver have been reported so far in the literature. This paper reports a case that caused a diagnostic dilemma.

[Development of modern physical diagnosis and its application in cardiothoracic surgery]

The year 2000 marked the 300th anniversary of the birth of Gerard Van Swieten (1700-1772). He reformed medicine in Vienna, putting new emphasis on diagnosis based on clinical observation in combination with anatomical-pathological findings. This led to the introduction by Leopold Auenbrugger (1722-1809) of percussion in the examination of thoracic organs. However, further work by Joseph Skoda (1805-1881) was required to finally establish this method as a diagnostic tool for pathologies in the thorax. The surgeon Franz Schuh (1804-1865) carried out further basic research in respiratory physiology that cleared the way for the use of percussion and auscultation in thoracic surgery. He is also remembered for introducing experimental surgery in Austria, thus making surgery a science. This article aims to recall these men and their fundamental work behind early paracentesis of the thorax, and especially the first successful pericardiotomy by Schuh 160 years ago, which is also considered a milestone in cardiac surgery.

Open thoracic meningocele associated with amniotic band syndrome

We present a case of an infant born with an open thoracic meningocele secondary to an amniotic band. Although there have been several case reports of encephalocele, anencephaly, closed meningocele and a case of tethered cord associated with amniotic band syndrome (ABS), there has yet to be a report of an open meningocele associated with ABS. The patient remained neurologically intact after the repair of his meningocele. His postoperative course was complicated by meningitis with subsequent hydrocephalus necessitating ventriculoperitoneal shunt placement.

Thoracic reconstruction with the omentum: indications, complications, and results

This study provides a retrospective analysis of 60 patients who underwent thoracic reconstruction with the omentum. Patients were identified by searching several databases to determine demographics, indications for surgery, operative technique, and postoperative course, including donor and recipient site morbidity. From January 1975 to May 2000, the authors harvested and transferred the omentum successfully (57 pedicled, 3 free) in 60 patients (mean age, 60 years; age range, 21-86 years) for sternal wound infections (N = 34), chest wall resections (N = 17), pectus deformities (N = 2), intrathoracic defects (N = 4), and breast reconstruction (N = 3). The omentum was used as a primary flap in 39 patients and as a salvage flap in 21 patients. Average operative time was 3.9 hours and average hospital stay was 34.3 days. Partial flap loss occurred in 7 patients, with no total flap failures. Morbidity included six abdominal wound infections and seven epigastric hernias. Mortality was 11.7%. The omentum can be harvested safely and used reliably to reconstruct varying thoracic wounds and defects. Specific indications from this series include osteoradionecrosis, chest wall tumors, massive sternal wounds, and refractory mediastinitis. Hultman CS, Culbertson JH, Jones GE, et al. Thoracic reconstruction with the omentum: indications, complications, and results.

Place of video-thoracoscopy in thoracic surgical practice

The advent of video-endoscopy revolutionizes the practice of surgery. Within a short span of time, video-assisted thoracic surgery (VATS) has become an acceptable approach to a wide range of thoracic procedures. The use of VATS as a diagnostic modality is now well established. For therapeutic procedures, VATS has also been generally accepted for the treatment of such conditions as primary spontaneous pneumothorax, loculated effusions, thoracodorsal sympathectomy, and resection of simple mediastinal cysts. Its roles in more complex procedures such as thymectomy and anatemic lung resections, however, remain poorly defined at present, even though the existing intermediate-term results are encouraging. VATS is still in evolution. Miniaturization of instruments promises to reduce access-induced trauma even further. On the other hand, attention to cost-containment is essential if VATS is to be applicable to patients in developing countries. Technology will continue to change. Carefully conducted clinical trials should precede the general acceptance of any new technology, no matter how attractive it may appear initially.

Hydatid disease of rib

Osseous hydatidosis, especially when located in the rib, is a very rare disease. In 1978, only 39 costal echinococcosis cases were published. The course of the disease is generally slow and laboratory tests are frequently negative. Diagnosis is generally made through the combined assessment of clinical, radiologic, and laboratory data. Living in a rural area is an important risk factor for the disease. The gold standard for therapy is radical removal of the involved ribs or chest wall. We present the case of a 63-year-old herdsman with costal echinococcosis and a review of the literature.

Hydatid disease of the liver with thoracic involvement

Hydatidosis, caused by Echinococcus granulosus, is an endemic parasitic disease in Mediterranean countries. The most frequent anatomic locations are liver and lung. Intrathoracic rupture of hydatid cysts situated in the hepatic dome is a serious complication resulting in damage to the pleura, pulmonary parenchyma, and bronchi. From January 1984 to December 1997 we operated on 40 patients with intrathoracic rupture of a hepatic hydatid cyst. Chest roentgenograms showed a shadow of varying size at the base of the hemithorax. Hepatic and thoracic ultrasonography was performed in all cases. The diagnosis of intrathoracic rupture of a liver cyst was confirmed preoperatively in 30 of the 40 cases. Posterolateral thoracotomy was performed in all patients. This transthoracic approach allowed adhesiolysis and treatment of the pleural lesions, pulmonary lesions, and hepatic cyst. Treatment of the diaphragmatic gap is easily done. We performed 15 lobectomies, 10 wedge resections, 16 decortications, and in one patient simple drainage of a voluminous pleuropulmonary and hepatic purulent hydatic collection. The postoperative course was uneventful in 26 cases, but 14 patients had complications, from which 3 patients died. The therapeutic approach depends on ultrasonographic findings. We believe ultrasonography to be the best examination for assessing biliary, hepatic, diaphragmatic, and pleuropulmonary lesions. When an intrathoracic collection is present, thoracotomy must be performed and is sufficient if the biliary tract is safe. An abdominal approach is necessary when biliary duct drainage is required, and it may be sufficient in cases of direct rupture into the bronchi.

[300 videothoracoscopy procedures--personal experience]

Videothoracoscopy and video-assisted thoracic surgery are by now already standard therapeutic procedures in thoracic surgery. The authors submit their experience with the method after 300 thoracoscopic operation at the surgical clinic of the Faculty Hospital in Plzen from the end of 1993 to the beginning of 2000. The main indications for this mini-invasive procedure is the treatment of spontaneous pneumothorax, diagnostic biopsy in pulmonary dissemination of obscure etiology, diagnosis and treatment of pleural exudates and elimination of minor peripheral pulmonary lesions. The authors discuss different surgical procedures in the most frequent diagnoses, their advantages and risks, indication criteria, complications. Attention is also paid to the causes of 10% conversions. In case of treatment of a spontaneous pneumothorax the authors consider videothoracoscopy as the method of first choice, while in case of primary carcinoma of the lungs they recommend the classical procedure. Other possibilities for the wider application of thoracoscopy and its development in their own department include in particular traumatic thoracic surgery.

Salivary gland choristoma of the anterior chest wall

Salivary gland choristoma (heterotopic salivary gland tissue) is a rare condition that occurs at various locations within the head and neck. Diagnostic criteria and embryogenesis of this entity remain unclear. Presented herein is the first reported case of salivary gland choristoma on the anterior chest wall. Surgical treatment is recommended.

[A method for the surgical treatment of patients with chronic postoperative osteomyelitis of the sternum]

The authors share their experiences with diagnosing and surgical treatment of chronic postoperative osteomyelitis of sternum developed in 36 patients after operations on the heart, lungs and organs of mediastinum. The purulent process can be liquidated in all the patients due to performing saving resection of the sternum and plasty of the bone defect with local tissues, application of a gauze-cotton roll pressing the subcutaneous fat into the bone defects formed after treatment of the affected portions of the sternum, administration of antibiotics according to sensitivity of the microflora.

Video-assisted thoracic surgery--state of the art

Video-assisted thoracic surgery (VATS) is one of the main medical revolutions of the past decade. For its satisfactory performance, the following prerequisites are essential: (1) knowledge and experience in thoracic surgery; (2) team of experienced anesthesiologists; (3) preoperative assessment of respiratory function; (4) adequate postoperative care; and (5) instruments specially designed for thoracoscopic surgery. VATS is routinely performed under general anesthesia with double lumen endotracheal intubation for separate control of each lung. Insufflation of carbon dioxide must not exceed 1-3 mm Hg. Too high pressure may cause harmful reduction of venous return and mediastinal shift with impairment of ventilation. Presence of adhesions should be determined by finger exploration of the pleural cavity. Operative ports should be placed carefully, avoiding damage to the intercostal nerves and vessels. The video technique can be used with efficiency for the following indications: pneumothorax, resection of pulmonary nodules, biopsies of lung, pleura and mediastinal structures, resection of mediastinal tumors, management of empyema, and hemostasis and closure of lacerations after trauma. Indications for esophageal procedures include esophagomyotomy for achalasia and resections of benign lesions. Repair of perforated esophagus is a matter of controversy, but in early stages it can be done thoracoscopically. Although video-pericardioscopy has been performed by some surgeons, this procedure can be done easier and faster using the direct approach without the video equipment. There are differences of opinion with regard to major pulmonary and esophageal resections for cancer. The apparent advantage of diminished pain is offset by inadequate resection, spread of malignant cells and potential damage to the resected specimen with loss of important information concerning pathology. Complications of VATS are few, and include prolonged air leak, dysrhythmia, respiratory failure, bleeding and infection. Due to progress over the past several years, VATS has become an inseparable part of thoracic surgery and should be included in the basic training of every thoracic surgeon.

[Five cases of surgically resected chronic expanding hematoma in the chest]

We report surgically treated 5 cases of chronic expanding hematoma in the chest. Three were male and two were female, aged 53 to 76. All patients except one who was thought to have an early stage of chronic expanding hematoma, had severe dyspnea due to compression of lung parenchyma or heart. Complete removal of the hematoma with fibrous capsule was done in two cases, but in three cases the hematoma was removed but the capsule was not because of severe adhesion to the surrounding structures. Post operative course was different to each other. One patient whose capsule was not removed completely have recurrent hematoma in the chest. The pulmonary or cardiac function were improved greatly except for the two cases; an early stage case and a recurrent case. We conclude that surgical removal is the first treatment for chronic expanding hematoma and complete removal of it with capsule is recommended.

Thoracoscopy in Horses

With the recent development of video-assisted thoracic surgery, visual inspection of the thoracic cavity has been used to provide a more accurate diagnosis and prognosis of thoracic diseases and to better manage these diseases. Equipment, techniques, and complications for standing thoracoscopy in horses are described.

Thoracic epidural lipomatosis with associated syrinx: case report

A 54-year-old black male with a 15-year history progressive lower extremity weakness was evaluated with a thoracic MRI that revealed epidural lipomatosis extending from T1-T10 with an associated syrinx at T1-3. He was neither overweight nor taking steroids. A multilevel thoracic laminectomy with resection of lipoma was performed without directly addressing the syrinx. Postoperatively, his symptoms improved and an MRI obtained 1 year after surgery demonstrated resolution of the syrinx. This is the only case of epidural lipomatosis with an associated syrinx that we have seen reported in the world literature.

[A new method of reconstruction for chest wall resection]

Sixteen patients who involved in chest wall disease underwent major chest wall resection between April 1995 and January 1999. The underlying diseases were 6 recurrence of breast cancers, 4 direct invasion by primary lung cancer, 2 metastatic chest wall tumor, one direct invasion by metastatic lung tumor, one direct invasion by metastatic mediastinal tumor, one radio-induced-necrosis of the chest wall, and one chest wall infection. In 9 patients, the thoracic cage reconstruction was performed using double sheets of absorbable mesh (Dexon mesh), cross string sutures and autologous ribs grafts. None of the patients had major respiratory failure and chest wall unstability. No late complications including infections, pains, recurrence and others related to reconstruction materials have been observed.

Multilevel thoracic pedicle aplasia causing congenital thoracic kyphosis: case report

OBJECTIVE AND IMPORTANCE

Congenital thoracic kyphosis is a rare cause of treatable myelopathy. Multilevel thoracic pedicle aplasia as a cause of this deformity has not been previously reported in the literature. We report a case and describe the surgical management and outcome.

CLINICAL PRESENTATION

A 14-year-old boy presented to us with a 4-month history of back pain and slowly progressive spastic paraparesis. Radiographic studies revealed thoracic kyphosis and bilateral aplasia of the pedicles of T4-T8.

INTERVENTION

The patient underwent surgical treatment via a posterior approach for decompression of T4-T8, followed by arthrodesis from T2 to T12, using a hook claw construct with multiple points of fixation and autologous bone grafting.

CONCLUSION

Congenital vertebral anomalies may be clinically occult, and delayed presentation may occur in adolescence or adulthood. Aplasia of multiple thoracic pedicles can produce kyphotic deformities with neurological compromise. A posterior approach with multiple points of segmental instrumentation can be effective in treating kyphotic deformities that are flexible and of moderate severity (<75 degrees).

Transdiaphragmatic abscess: late thoracic complication of laparoscopic cholecystectomy

Spillage of gallstones into the peritoneal cavity is a frequent problem during laparoscopic cholecystectomy (as much as 30%) and is frequently dismissed as a benign occurrence. However, several complications associated with spillage of gallstones have been reported recently. Most of these complications presented late after the original procedure, many with clinical pictures not related to biliary etiology, confounding and delaying adequate management. For patients presenting with intraabdominal or thoracic abscesses of unknown etiology, if there is a history of laparoscopic cholecystectomy, regardless of the time interval, certain evaluations should be considered. A sonogram and a CT scan are advisable to detect retained extraluminal gallstones, as most patients will require, not only drainage of fluid collections, but also removal of the stones. A case is described of a patient who presented with a right empyema and transdiaphragmatic abscess 18 months after a laparoscopic cholecystectomy. Treatment included decortication, enbloc resection of the abscess, repair of the diaphragm, and drainage.

Cognitive decline after major noncardiac operations: a preliminary prospective study

BACKGROUND

Cardiac operations frequently are complicated by postoperative cognitive decline. Less common and less studied is postoperative cognitive decline after noncardiac surgery, so we determined its incidence, severity, and possible predictors.

METHODS

Twenty-nine patients who had thoracic and vascular procedures were studied. A neurocognitive test battery was administered preoperatively and 6 to 12 weeks postoperatively. A change score (preoperative minus postoperative) was calculated for each measure in each individual. Cognitive deficit (a measure of incidence) was defined as a 20% decrement in 20% or more of the completed tests. The average scores of all tests and the average decline (a measure of severity) were determined.

RESULTS

The incidence of cognitive deficit was 44.8%. Overall the severity of the decline was an average of 15% decline. In the 44.8% of patients who had cognitive deficit, the severity was 24.7%. Multivariable predictors of cognitive decline were age (for incidence and severity) and years of education (for severity).

CONCLUSIONS

Cognitive decline after noncardiac operations is a frequent complication of surgical procedures. The severity could preclude successful return to a preoperative lifestyle.

[Surgical video-thoracoscopy]

Surgical video thoracoscopy represents a new surgical approach to thoracic disease. Its objective is to limit thoracotomy trauma to the pleural wall and at the same time to eliminate the consequences of post-thoracotomy pain and post-operative respiratory dysfunction. There are certain indications which are already accepted as the gold standard, others still require validation and the inverse that certain interventions will probably be excluded from the domain of video thoracoscopy with acquired experience. The best indications are: the treatment of spontaneous pneumothorax in a young person, lung biopsy, the excision of peripheral parenchymal nodules of uncertain aetiology, the diagnostic approach to mediastinal adenopathy notably nodes which are inferiorly situated and inaccessible to mediastinoscopy or anterior mediastinotomy, the debridement of purulent pleurisy and/or haemothorax, the initial exploration before thoracotomy of a pulmonary tumour accompanied by a pleural effusion which may be minimal or irregularities of the parietal pleura, a thoracic sympathectomy, pleural symphysis for pleural tumour pathology, the pleuropericardial fenestration in cases of double pathology, pleural and pericardial requiring both a diagnostic approach and symphysis.

Diagnostic thoracoscopy

Thoracoscopy is a minimally invasive diagnostic technique that provides access to the thoracic cavity for evaluation of intrathoracic pathology without surgical intervention. Intrathoracic structures can be visualized better with thoracoscopy than with an open thoracotomy. Indications for thoracoscopy include pleural effusion, pericardial effusion, intrathoracic masses, pneumothorax, primary pulmonary disease, and trauma. Thoracoscopy is technically similar to laparoscopy, using the same basic instrumentation and principles, but is easier to perform than laparoscopy. Patient preparation, anesthesia, and patient positioning are essentially the same for thoracoscopy as for a standard open thoracotomy. Thoracoscopy provides minimally invasive access to important diagnostic information with a very low incidence of complications.

Acute respiratory failure associated with intrathoracic masses in neonates

BACKGROUND

Intrathoracic masses are uncommon in children. Occasionally, they present with acute respiratory failure in the neonatal period. Although emergency resection usually is the treatment of choice, other modalities are sometimes necessary to stabilize the patient.

METHODS

Seven neonates with intrathoracic masses were treated. Five had congenital cystic adenomatoid malformations (CCAM), 1 had a mediastinal teratoma, and 1 had a pneumatocele. These cases were reviewed retrospectively.

RESULTS

Four of the 7 infants had respiratory failure in the neonatal period. A patient with a large mediastinal teratoma and 1 with a CCAM that increased rapidly after presentation underwent emergency operation, relieving respiratory distress. The other 2 large CCAMs presented with severe respiratory distress immediately after birth because of pulmonary hypoplasia. One neonate with a Stocker-I CCAM died after emergency resection. One more recent patient with a Stocker-III CCAM survived after successful treatment with delayed resection, performed 3 days after birth. Nitric oxide (NO), and extracorporeal membrane oxygenation (ECMO) were instituted as supportive care because of profound persistent fetal circulation (PFC).

CONCLUSIONS

Acute respiratory failure associated with intrathoracic masses in neonates may be managed in 1 of 2 ways. A small mass that increases rapidly should be resected soon after presentation. In neonates with large masses with associated PFC, surgery can be delayed until the patient is stable. ECMO, NO, and high-frequency oscillation (HFO) can be used aggressively for stabilizing such neonates.

[Use of leukinferon for prophylaxis of pyogenic complications in victims with thoracic wounds]

The results of treatment of 131 victims with penetrating wounds of the thorax complicated by profuse bleeding, are presented. 36 of them after surgery to prevent pyogenous complications received 5 injections of leukinferon (test group); 95 patients who were not treated by leukinferon made up control group comparable with the test group by sex, age and character of wounds. Comparative analysis of the results showed that treatment with leukinferon has resulted in decrease of postoperative complications. In the test group the number of complications made up 47.2%, in control group--61%. Al the same time in the former group there was only one pyogenous complication (2.9%), while in control group--10 (10.6%). After the course of leukinferon leucocytic formula of the blood has become normal, the number of patients with immunodeficiency and imbalance of proteins markers of the acuteness of inflammatory process has decreased.

Polyvisceral echinococcosis with involvement of the heart and chest wall: follow-up and review of literature

Echinococcosis remains an endemic surgical problem in countries where sheep and cattle raising is carried out, particularly in many Mediterranean countries. The life cycle of echinococcosis is usually marked by the filtration of larvae through the liver and lungs which are the organs most commonly affected by a hydatid cyst. Hydatid cysts in other sites are not common. Cardiac echinococcosis has been reported infrequently even in countries in which hydatid disease is endemic, only isolated sporadic cases have been reported in the literature. Here we report a case of polyvisceral hydatid cyst with involvement of heart and chest wall and reviewed the literature and discussed clinical procedures and management.