Thoracic compartment syndrome secondary to a thoracic procedure: a case report

Prolonged open sternotomy is a well-known phenomenon in the pediatric and adult cardiac surgery literature. It is usually an adjuvant in the treatment of a severely compromised heart. We present a case of thoracic compartment syndrome that developed postoperatively from a noncardiac thoracic procedure. Management, diagnosis, and literature review are presented.

Catamenial pneumothorax: a prospective study

OBJECTIVES

To evaluate the incidence of catamenial pneumothorax (CP) among women who have been referred for the surgical treatment of spontaneous pneumothorax (SP) and to study its pathogenic mechanisms.

DESIGN

A prospective study of women of reproductive age who have been referred to our center for the surgical treatment of SP. Patients with pneumothorax secondary to a known lung disease were excluded.

SETTING

A university hospital.

METHODS

At the preoperative evaluation, special attention was given to the investigation of a possible temporal relationship between pneumothorax and menses. Video-assisted thoracoscopy constituted the operative technique of choice. The lung was inspected to identify blebs or bullae and the origin of possible air leaks. Signs of thoracic endometriosis were also carefully searched for. The diaphragm was systematically inspected to search for holes and/or endometrial implants. When limited diaphragmatic abnormalities were found, a partial diaphragmatic resection was carried out using an endoscopic stapler. In case of lesions that were not accessible by a purely endoscopic approach, a utility minithoracotomy was used.

RESULTS

In an 18-month period, 32 women with SP were referred for surgery. In eight cases, the catamenial character of the pneumothorax was recognized by clinical history. In all these patients, the following diaphragmatic abnormalities were found at surgery: holes (one patient); endometrial implants (three patients); and both (four patients). Visceral pleural endometriosis was found in one patient. During pathologic examination, diaphragmatic endometriosis was confirmed in seven of the eight cases. In one patient, it was associated with pulmonary and pleural endometriosis. In only one patient (with multiple diaphragmatic holes and a pulmonary nodular brown lesion), endometriosis could not be confirmed at histology, but signs of parenchymal focal hemorrhages were found.

CONCLUSIONS

Our experience shows that (1) CP is more frequent than expected and (2) diaphragmatic abnormalities seem to play a fundamental role in its pathogenesis.

[Unilateral laryngeal paralyses: epidemiological data and therapeutic progress]

OBJECTIVES

Analysis of the epidemiology and progress in treatment of unilateral laryngeal nerve paralysis.

METHOD

A retrospective study in a cohort of 325 patients (1989-2001) with unilateral laryngeal nerve paralysis.

RESULTS

The sex ratio was 1:2. Age varied from 16 to 98 years (mean age: 55 years). Symptoms included dysphonia in 321 patients, swallowing impairment in 126 patients and dyspnea on exertion in 3 patients. Etiologies were post-surgical (243 patients) predominantly thyroid and thoraco-mediastinal surgery, idiopathic (39 patients), tumoral (28 patients), non-surgical traumatism (8 patients) and medical causes (7 patients). The paralysis was globally related to a neoplastic disease in 50% of cases. Analysis of the evolution of the etiologies over time revealed an increase in the post surgical causes and paralysis related to a neoplastic diseases. Spontaneous recovery of unilateral laryngeal nerve paralysis occurred in 23% of patients. Surgical rehabilitation was performed in 44% of patients (thyroplasty under local anesthesia in 55 patients and intracardal injection under general anesthesia in 88 patients). The analysis of the evolution of treatment modalities showed: an increasing number of patients undergoing surgical rehabilitation, an increasing number of patients undergoing surgery under local anesthesia (thyroplasty) and an increasing number of patients refusing any surgical rehabilitation.

CONCLUSION

Analysis of the data underlined the changes in the distribution of the etiologies and treatments of unilateral laryngeal nerve paralysis.

[Intrathoracic chronic expanding hematoma; report of a case]

A case of a patient with a intrathoracic chronic expanding hematoma presenting as a neoplasm is reported. A chronic encapsulated intrathoracic hematoma is rare condition and is clinically included in a category of chronic hemorrhagic empyemas as a type of chronic empyemas in Japan. The clinical picture of our case suggested a slowly growing tumor. Though needle biopsy was performed, only blood was aspirated. Intraoperative findings revealed a intrathoracic hematoma with a tough capsule. It adhered to the chest wall hardly. Histopathological investigations revealed that the capsule consisted of a collagenous outer layer and a newly vascularized inner layer with fibrosis. Hemosiderin deposits suggested recurrent bleeding from fragile vessels. The mechanisms of hematoma formation and its expanding nature are discussed. The hematoma appeared to have been enlarged by repeated exudation or bleeding from capillaries inside the capsule.

Endogenous glycosides in critically ill patients

OBJECTIVE

To determine the incidence of critically ill patients displaying endogenous digitalis-like-immunoreactive substances (DLIS) and to examine the relationship of these hormones to routine laboratory variables, the underlying disease, myocardial function, hemodynamic status, severity of illness, systemic inflammation, and mortality rate.

DESIGN

Sera of 401 consecutive critically ill patients, not treated with cardiac glycosides, were analyzed for DLIS (digitoxin and digoxin, TDx; Abbott Diagnostics, North Chicago, IL) and endogenous ouabain. Normal values of endogenous ouabain were determined in 62 healthy volunteers. We measured pro- and anti-inflammatory mediators (L-selectin, tumor necrosis factor-alpha, interleukin-1beta, interleukin-2, interleukin-6, interleukin-10), C-reactive protein, and serum amyloid A protein as well as patients' Acute Physiology and Chronic Health Evaluation II and Goris scores. In a subgroup of patients with a pulmonary artery catheter (n = 95), we determined cardiac output, pulmonary artery occlusion pressure, systemic and pulmonary vascular resistance, left ventricular stroke volume, and right and left stroke work.

SETTING

Two surgical intensive care units of an university hospital.

SUBJECTS

Sera of 401 consecutive critically ill patients.

INTERVENTIONS

Blood sampling.

MEASUREMENTS AND MAIN RESULTS

Of the 401 patients tested, 343 had nonmeasurable DLIS concentrations (DLIS-negative), and 58 (14.5%) had positive digoxin (n = 18) or digitoxin (n = 34) concentrations (DLIS-positive) or were positive in both tests (n = 6). Mean endogenous ouabain concentrations were nine-fold increased in DLIS-positive (3.59 +/- 1.43 nmol/L) and three-fold increased in DLIS-negative (1.34 +/-.81 nmol/L) patients compared with controls (0.38 +/- 0.31 nmol/L). DLIS and ouabain concentrations closely correlated with the Acute Physiology and Chronic Health Evaluation II and Goris score and were associated with increased concentrations of transaminases, bilirubin, aldosterone, cortisol, serum creatinine, fractional sodium excretion, proinflammatory mediators, C-reactive protein, and serum amyloid A (p <or=.009). The hospital mortality rates of DLIS-positive and DLIS-negative patients were 12% and 3.2%, respectively, and for patients with ouabain concentrations above and below 2 nmol/L 38.6% and 0.6%, respectively. In DLIS-positive patients with pulmonary artery catheter (n = 23), cardiac output, stroke volume, and left ventricular stroke work were decreased, and pulmonary artery occlusion pressure and central venous pressure were increased (p <or=.009).

CONCLUSIONS

Different types of endogenous glycosides including endogenous ouabain are elevated in a significant proportion of critically ill patients. The occurrence of these substances is associated with increased morbidity and hospital mortality rates, possibly due to systemic inflammatory processes. DLIS but not endogenous ouabain concentrations were found to be related to left ventricular function.

[Virtual surgeries based on spiral computed tomography]

Experience of spiral computed tomography with bolus contrast enhancement and subsequent 3D-reconstruction of picture for virtual modeling of surgeries is presented. The method was used in 204 patients with tumors and diseases of the liver, pancreas, spleen, kidneys, adrenal glands, parapapillary diverticula of the duodenum, coarctations and aneurysms of aorta, extraorganic tumors of the retroperitoneal cavity and neck. Coincidence of virtual and real types of surgeries reached 75-92.8% depending on the disease and clinical situation. Perspectives of 3D-reconstruction for evaluation of normal and pathologic anatomic features in an individual patient, choice of an optimal surgical variant, prognosis of possible complications and their prophylaxis are demonstrated. Integration of surgeon's and radiologist's thinking is very important for correct diagnosis and surgical policy.

[Endoscopic thoracic surgery: indications, feasibility, and limitations]

Mediastinoscopy and mediastinotomy are used primarily in the staging of lung cancer; they are also of value in biopsying mediastinal masses and lymph nodes to establish diagnoses such as sarcoidosis,lymphoma, and mediastinal tumors. Video-assisted thoracic surgery (VATS) was introduced in 1990 and has now replaced open thoracotomy in the evaluation of many pleuropulmonary disorders. Specific advantages of VATS over open thoracotomy include the use of smaller incisions, reduced operative morbidity, and optimal visualization of the entire lung and pleural space. In many centers it has become the procedure of choice for the biopsy of interstitial disease, indeterminate lung nodules, or pleural lesions. The role of VATS for staging of lung cancer patients is still under debate. VATS procedures have also been adopted for the treatment of a wide range of thoracic disorders. With increasing experience surgeons have become more skilled with this limited access technique and meanwhile lobectomies can be performed safely. The role of VATS in the management of lung metastases or lung cancer is still being investigated. It is a concern that there is a temptation to do less when a minimal access operation is performed that does not allow for palpation of the lung. In addition, lymph node dissection cannot be performed adequately and there continue to be reports of local recurrences in port sites. If the VATS approach is to be used, surgeons should always respect the oncological principles that have been developed over the past decades.

The role of thoracoscopy in pediatric surgical practice

Originally described in the early 20th century, the technique of thoracoscopy was first applied to children in the mid 1970s. Since that time, the technique has become adopted widely by pediatric surgeons and is currently considered to be the optimum technique for management of many intrathoracic disorders in children. In most pediatric surgical practices, the most common indications for thoracoscopy include pleural debridement for empyema, mediastinal lymph node biopsy, and pulmonary parenchymal biopsy for inflammatory infiltrates or nodules. With proper adherence to patient selection and preoperative imaging as well as appropriate anesthetic techniques, this procedure has proven to be extremely accurate in achieving a diagnosis and very successful in treating most patients. Postoperative recovery is rapid, and complications of the procedure have been relatively infrequent. As pediatric surgeons gain more experience with this technique and as better instrumentation becomes available, thoracoscopy surely will be used for an increasing number of complex intrathoracic disorders.

Limitations of technetium 99m sestamibi scintigraphic localization for primary hyperparathyroidism associated with multiglandular disease

Successful surgical treatment of primary hyperparathyroidism requires the localization and excision of the parathyroid tissue responsible for excessive parathyroid hormone secretion while ensuring that the patient will have sufficient endogenous parathyroid hormone production to maintain eucalcemia. In selecting patients with primary hyperparathyroidism for unilateral parathyroidectomy the surgeon should be able to diagnose multiglandular disease either preoperatively or intraoperatively. We performed a retrospective review of 123 patients who underwent surgical treatment for primary hyperparathyroidism to determine the potential feasibility of selecting patients for minimally invasive surgery based on preoperative imaging studies. All patients were studied preoperatively with 99m technetium-sestamibi scintigraphy. High-resolution ultrasonography was performed in 119 of these patients. All patients except one underwent bilateral cervical exploration. A patient with an intrathoracic adenoma was successfully diagnosed by scintigraphy thereby allowing treatment by a limited thoracotomy. One hundred eight patients had solitary adenomas and 15 had multiglandular disease. In none of the patients with bilateral multiglandular disease were all abnormal glands localized preoperatively. Patients in our study with primary hyperparathyroidism and multiglandular disease were underdiagnosed by preoperative imaging. A minimally invasive approach based solely on preoperative imaging studies may result in treatment failure in patients with multiglandular involvement.

Percutaneous nephrolithotomy of an intrathoracic kidney

We present a 35-year-old woman with symptomatic urolithiasis in an intrathoracic kidney. Percutaneous nephrolithotomy was successfully performed after ureteroscopy failed because of the unusual length of the ureter associated with the kidney position. We report the first case of percutaneous nephrolithotomy of an intrathoracic kidney.

[Diagnosis and treatment of post-traumatic coagulated hemothorax]

Analysis of 102 cases of coagulated hemothorax (CH) are presented: 32--after penetrating wounds and 70--after closed chest injury. In 57% patients with chest wounds and 72% patients with closed injury the cause of CH was to applying late for medical care. Diagnostic value of X-ray, ultrasonic methods, CT and pleural puncture was studied. Depending on the patients state severity, CH volume and stage of it formation conservative treatment, streptase administration, thoracoscopy and thoracotomy with pleurectomy and lung decortication were performed. Lethality was 2.9%.

Prenatal therapy for thoracic and mediastinal lesions

Most prenatally diagnosed lung lesions can be managed successfully during the neonatal period. Prenatal imaging and experimental models have provided a comprehensive understanding of the pathophysiology, natural history, and prognosis of intrathoracic and mediastinal lesions. Clinical experience has demonstrated that progression to nonimmune hydrops fetalis and pulmonary hypoplasia is a harbinger of fetal or neonatal demise. Advances in fetal anesthesia, tocolysis, and surgical techniques have made fetal surgery a viable in utero option to ameliorate life-threatening masses. Congenital cystic adenomatoid malformation, bronchopulmonary sequestration, and congenital hydrothorax are the most common abnormalities amenable to surgical intervention. The natural history, evaluation, and treatment of intrathoracic and mediastinal lesions are discussed.

Intrathoracic giant meningocele developing hydrothorax: a case report

A 67-year-old woman with neurofibromatosis type 1 presented with progressive dyspnea. Radiologic evaluation and magnetic resonance imaging revealed progression of a giant meningocele associated with hydrothorax. Laminoplasty with incision of the meningocele and dural plasty was performed, although nerve rootlets were killed. Microsurgical incision of the neck of the meningocele is a favorable operation even in large meningoceles such as the present case.

Resolution of Chiari malformation after repair of a congenital thoracic meningocele: case report and literature review

OBJECTIVE AND IMPORTANCE

Many theories have been proposed regarding potential causative factors for Chiari malformations. An unusual case is described in which regression of a congenital Chiari malformation was observed after repair of a thoracic meningocele without direct surgical intervention to decompress the craniocervical junction. This supports the importance of an in utero craniospinal pressure gradient as a potential cause for congenital, but reversible, cerebellar herniation.

CLINICAL PRESENTATION

A newborn baby was observed to have a thoracic meningocele. Magnetic resonance imaging scan revealed a concomitant Chiari malformation. No neurological deficits were present at initial examination.

INTERVENTION

The patient underwent surgical closure of the thoracic meningocele and untethering of the spinal cord at the site of the dural defect. A postoperative magnetic resonance imaging scan obtained 3 months after the operation revealed complete resolution of the cerebellar herniation.

CONCLUSION

The resolution of the Chiari malformation in this child may have resulted from restoration of normal cerebrospinal fluid flow and elimination of the meningocele-related cerebrospinal fluid pressure gradient between the intracranial and intraspinal compartments.

Thoracic intramedullary cysticercosis--two case reports

A 36-year-old male and a 20-year-old male presented with intramedullary cysticercosis in the thoracic spinal cord. Magnetic resonance imaging clearly identified the cysts. Surgery was performed to decompress the spinal cord, as both patients had progressive and severe worsening of their neurological condition. Intramedullary cysticercosis can be treated successfully by surgery and/or medical therapy.

Clinical experience of surgical therapy in 207 patients with thoracic hydatidosis over a 12-year-period

PRINCIPLES

Hydatid disease is the most severe helminthic zoonosis, with a major medical, social, and economic impact in Turkey. The aim of this study was to evaluate retrospectively 207 patients diagnosed with hydatid cyst and treated surgically in our department between January 1990 and December 2001.

METHODS

Hundred and ninety three patients were male and 14 female. They ranged in age from 19 to 72 years (mean 25.3 years). The most common presenting symptoms were cough, expectoration and chest pain. The surgical approach was thoracotomy in 198 patients, bilateral staged thoracotomies in 5 patients, median sternotomy in one patient and video-assisted thoracic surgery in 3 patients.

RESULTS

Hundred and thirty eight of the 265 intrapulmonary cystic lesions were found in the right lung and 127 in the left lung. Intrathoracic extrapulmonary cystic lesions were detected in 13 patients. 38 patients also had cystic lesions in the liver. Conservative surgical procedures were adopted except for small wedge resections in 8 patients, segmentectomy in 4 patients and lobectomy in one. Operative and postoperative mortality was nil. Albendazole treatment was given to patients who had multiple intrathoracic cysts or additional hepatic cysts after 1994.

CONCLUSIONS

Our preferred surgical techniques for removal of cysts were conservative surgical procedures such as enucleation of cysts or removal by cystotomy. Radical procedures such as pneumonectomy, lobectomy and segmentectomy should be avoided as far as possible.

Comparative analysis of pedicle screw and hook instrumentation in posterior correction and fusion of idiopathic thoracic scoliosis

Posterior correction and fusion with segmental hook instrumentation represent the gold standard in the surgical treatment of progressive idiopathic thoracic scoliosis. However, there is a debate over whether pedicle screws are safe in scoliosis surgery and whether their usage might enable a better curve correction and a shorter fusion length. The details of curve correction, fusion length and complication rate of 99 patients with idiopathic thoracic scoliosis treated with either hook or pedicle screw instrumentation were analyzed. Forty-nine patients had been operated with the Cotrel-Dubousset system using hooks exclusively ("hook group"). Fifty patients had been operated with either a combination of pedicle screws in the lumbar and lower thoracic and hooks in the upper thoracic spine or exclusive pedicle screw instrumentation using the Münster Posterior Double Rod System ("screw group"). The preoperative Cobb angle averaged 61.3 degrees (range 40 degrees-84 degrees ) in the hook group and 62.5 degrees (range 43 degrees-94 degrees ) in the screw group. Average primary curve correction was 51.7% in the hook group and 55.8% in the screw group ( P>0.05). However, at follow-up (2-12 years later) primary curve correction was significantly greater ( P=0.001) in the screw group (at 50.1%) compared to the hook group (at 41.1%). Secondary lumbar curve correction was significantly greater ( P=0.04) in the screw group (54.9%) compared to the hook group (46.9%). Correction of the apical vertebral rotation according to Perdriolle was minimal in both groups. Apical vertebral translation was corrected by 42.0% in the hook group and 55.6% in the screw group ( P=0.008). Correction of the tilt of the lowest instrumented vertebra averaged 48.1% in the hook group and 66.2% in the screw group ( P=0.0004). There were no differences concerning correction of the sagittal plane deformity between the two groups. Fusion length was, on average, 0.6 segments shorter in the screw group compared to the hook group ( P=0.03). With pedicle screws, the lowest instrumented vertebra was usually one below the lower end vertebra, whereas in the hook group it was between one and two vertebrae below the lower end vertebra. Both operative time and intraoperative blood loss were significantly higher in the hook group ( P<0.0001). One pedicle screw at T5 was exchanged due to the direct proximity to the aorta. There were no neurologic complications related to pedicle screw instrumentation. Pedicle screw instrumentation alone or in combination with proximal hook instrumentation offers a significantly better primary and secondary curve correction in idiopathic thoracic scoliosis and enables a significantly shorter fusion length.

[Video-assisted thoracoscopy (VATS) during the last ten years (1992-2001)]

We summarize and analyse the video-assisted thoracoscopies (VATS) performed in our department during the last ten years. In this period 296 patients underwent VATS for diagnosis or therapy. We describe indications, advantages and disadvantages, we also analyse the complications. Video-assisted thoracoscopy is less demanding to the patients than thoracotomy, it reduces the length and cost of inpatient treatment. We recommend extensive use of VATS in suitable patients.

Use of endoscopic transthoracic sympathicotomy in intractable postherpetic neuralgia of the chest

Although there are various treatments for postherpetic neuralgia (PHN), none produces definitive effects. We report a case of 72-year-old woman who developed intractable PHN of the chest in which treatment with endoscopic transthoracic sympathicotomy (ETS) produced long-term effective results. When hyperesthesia of the sympathetic nerve participates in PHN, the blocking of sympathetic excitation seems to be effective for PHN suppression. The method using a single resectoscope is safe, accurate, yields excellent results cosmetically, and generates minimal invasion and very little postoperative pain. Although ETS is not always effective for all cases of PHN, it could be a useful method of treating patients with PHN that is resistant to conventional therapies.

Necrotizing soft tissue infection of the chest wall

Necrotizing soft tissue infection (NSTI) of the chest wall is a relatively rare but highly lethal surgical infection which has received little attention in the medical and surgical literature. The data reported are based on a literature review, including a Medline database search, and search of existing bibliographies. Twenty well-documented cases of primary chest wall involvement by NSTI were found. Thirteen patients were male. Patients' ages ranged from 10 weeks to 78 years. Thirteen patients were postoperative (65%). The diagnosis was initially considered in only 3 of the postoperative cases, a cause of significant delays in surgical treatment. Among those who lived long enough for their wounds to close, 2 had secondary healing, 5 experienced delayed skin grafting over the granulating wound, and 1 had skin grafting combined with muscle transfer. Mortality was 60%. Chest wall NSTI is a rapidly spreading, highly lethal infection. A high index of suspicion, early diagnosis, and aggressive approach are essential to its successful treatment.