The Potential Impact of Intrathoracic Impedance on Defibrillation Threshold Testing in S-ICDs.

A man with an ischemic cardiomyopathy and chronic obstructive pulmonary disease underwent subcutaneous implantable cardioverter-defibrillator (S-ICD) placement under general anesthesia. Following induction of ventricular fibrillation (VF), defibrillation testing (65J) failed, requiring external rescue. Repeat shock testing with reversed polarity (65J) failed. A third shock and external defibrillation failed (80J and 200J), followed by a second external defibrillation (200J), which did not immediately terminate VF, and a device shock 2 seconds later (80J, successful). Repeat shock testing (80J) under conscious sedation without mechanical ventilation was successful. We discuss this case of failed defibrillation testing during S-ICD placement, potentially due to lung hyperinflation, requiring double sequential defibrillation.

Imaging respiratory muscle quality and function in Duchenne muscular dystrophy.

OBJECTIVE: Duchenne muscular dystrophy (DMD) is characterized by damage to muscles including the muscles involved in respiration. Dystrophic muscles become weak and infiltrated with fatty tissue, resulting in progressive respiratory impairment. The objective of this study was to assess respiratory muscle quality and function in DMD using magnetic resonance imaging and to determine the relationship to clinical respiratory function. METHODS: Individuals with DMD (n = 36) and unaffected controls (n = 12) participated in this cross sectional magnetic resonance imaging study. Participants underwent dynamic imaging of the thorax to assess diaphragm and chest wall mobility and chemical shift-encoded imaging of the chest and abdomen to determine fatty infiltration of the accessory respiratory muscles. Additionally, clinical pulmonary function measures were obtained. RESULTS: Thoracic cavity area was decreased in individuals with DMD compared to controls during tidal and maximal breathing. Individuals with DMD had reduced chest wall movement in the anterior-posterior direction during maximal inspirations and expirations, but diaphragm descent during maximal inspirations (normalized to height) was only decreased in a subset of individuals with maximal inspiratory pressures less than 60% predicted. Muscle fat fraction was elevated in all three expiratory muscles assessed (p < 0.001), and the degree of fatty infiltration correlated with percent predicted maximal expiratory pressures (r = - 0.70, p < 0.001). The intercostal muscles demonstrated minimal visible fatty infiltration; however, this analysis was qualitative and resolution limited. INTERPRETATION: This magnetic resonance imaging investigation of diaphragm movement, chest wall movement, and accessory respiratory muscle fatty infiltration provides new insights into the relationship between disease progression and clinical respiratory function.

Management of intrathoracic and cervical anastomotic leakage after esophagectomy for esophageal cancer: a systematic review.

Background: Anastomotic leakage (0-30%) after esophagectomy is a severe complication and is associated with considerable morbidity and mortality. The aim of this study was to determine which treatment for anastomotic leakage after esophagectomy have the best clinical outcome, based on the currently available literature. Methods: A systematic literature search was performed in Medline, Embase, and Web of Science until April 2017. All studies reporting on the specific treatment of cervical or intrathoracic anastomotic leakage following esophagectomy with gastric tube reconstruction for esophageal or cardia cancer were included. The primary outcome parameter was postoperative mortality. Methodological quality was assessed by the Newcastle-Ottawa Quality Assessment Scale. Results: Nineteen retrospective cohort studies including 273 patients were identified. Methodological quality of all studies was poor to moderate. Mortality rates of intrathoracic anastomotic leakages in the treatment groups were as follows: conservative (14%), endoscopic stent (8%), endoscopic drainage (8%), endoscopic vacuum-assisted closure system (0%), and surgery treatment group (50%). Mortality rates of cervical anastomotic leakages in the treatment groups were as follows: conservative (8%), endoscopic stent (29%), and endoscopic dilatation (0%). Discussion: Due to small cohorts, heterogeneity between studies, and lack of data regarding leakage characteristics, no evidence supporting a specific treatment for anastomotic leakage after esophagectomy was found. A severity score based on leakage characteristics instead of treatment given is essential for determining the optimal treatment of anastomotic leakage. In the absence of robust evidence-based treatment guidelines, we suggest customized treatment depending on sequelae of the leak and clinical condition of the patient. PrDepartment of Surgery, Radboudumc, P.O.B. 9101/618 NLactical advices are provided. Trial registration: Registration number PROSPERO: CRD42016032374.

Use of intrathoracic pressure regulation therapy in breathing patients for the treatment of hypotension secondary to trauma.

BACKGROUND: Intrathoracic pressure regulation (IPR) therapy has been shown to increase blood pressure in hypotensive patients. The potential value of this therapy in patients with hypotension secondary to trauma with bleeding is not well understood. We hypothesized that IPR would non-invasively and safely enhance blood pressure in spontaneously breathing patients with trauma-induced hypotension. METHODS: This prospective observational cohort study assessed vital signs from hypotensive patients with a systolic blood pressure (SBP) ≤90 mmHg secondary to trauma treated with IPR (ResQGARD™, ZOLL Medical) by pre-hospital emergency medical personnel in three large US metropolitan areas. Upon determination of hypotension, facemask-based IPR was initiated as long as bleeding was controlled. Vital signs were recorded before, during, and after IPR. An increased SBP with IPR use was the primary study endpoint. Device tolerance and ease of use were also reported. RESULTS: A total of 54 patients with hypotension secondary to trauma were treated from 2009 to 2016. The mean ± SD SBP increased from 80.9 ± 12.2 mmHg to 106.6 ± 19.2 mmHg with IPR (p < 0.001) and mean arterial pressures (MAP) increased from 62.2 ± 10.5 mmHg to 81.9 ± 16.6 mmHg (p < 0.001). There were no significant changes in mean heart rate or oxygen saturation. Approximately 75% of patients reported moderate to easy tolerance of the device. There were no safety concerns or reported adverse events. CONCLUSIONS: These findings support the use of IPR to treat trauma-induced hypotension as long as bleeding has been controlled.

Thoracic fluid content by electric bioimpedance correlates with respiratory distress in newborns.

OBJECTIVE: The objective of the study was to compare thoracic fluid content (TFC) between newborn infants with and without respiratory distress. We tested the hypothesis that TFC would be higher in infants with respiratory distress. STUDY DESIGN: A total of 96 newborn infants, gestational age 37.9 (2.6) weeks, were enrolled at birth. TFC by electrical bioimpedance was recorded within 3 h after birth (TFC1) and at 24 h of life (TFC2). RESULTS: TFC1 was higher in infants with respiratory distress at birth (76.8 (24.9) versus 61.6 (16.1) 1 KOhm-1, P<0.0005). The association was independent from gestational age and mode of delivery. TFC2 was independently associated with respiratory distress at 24 h of life (adjusted coefficient b=0.5 (s.d. 0.02), P=0.02). CONCLUSION: TFC by electric bioimpedance independently correlated with the presence of respiratory distress at birth and at 24 h of life in late preterm and term newborn infants.

Assessment of Changes in Hemodynamics and Intrathoracic Fluid Using Electrical Cardiometry During Autologous Blood Harvest.

OBJECTIVE: To evaluate the effect of autologous blood harvest (ABH)-induced volume shifts using electrical cardiometry (EC) in patients with pulmonary artery hypertension secondary to left heart disease. DESIGN: Prospective, randomized, controlled trial. SETTING: A tertiary care hospital. PARTICIPANTS: The study comprised 50 patients scheduled to undergo heart valve replacement. INTERVENTIONS: Patients were divided randomly into 2 experimental groups that were distinguished by whether ABH was performed. Blood volume extracted in the test group was replaced simultaneously with 1:1 colloid (Tetraspan; B Braun Melsungen, Melsungen, Germany). Hemodynamic, respiratory, and EC-derived parameters were recorded at predefined set points (T1 [post-induction/pre-ABH] and T2 [20 minutes post-ABH]). MEASUREMENTS AND MAIN RESULTS: Withdrawal of 15% of blood volume in the ABH group caused significant reductions in thoracic fluid content (TFC) (-10.1% [-15.0% to -6.1%]); right atrial pressure (-23% [-26.6% to -17.6%]); mean arterial pressure (-12.6% [-22.2% to -3.8%]); airway pressures: (peak -6.2% [-11.7% to -2.8%] and mean -15.4% [-25.0% to -8.3%]); and oxygenation index (-10.34% [-16.4% to -4.8%]). Linear regression analysis showed good correlation between the percentage change in TFC after ABH and the percentage of change in right atrial pressure, stroke volume variation, autologous blood extracted, peak and mean airway pressures, and oxygen index. CONCLUSIONS: In addition to its proven role in blood conservation, therapeutic benefits derived from ABH include decongestion of volume-loaded patients, decrease in TFC, and improved gas exchange. EC tracks beat-to-beat fluid and hemodynamic fluctuations during ABH and helps in the execution of an early patient-specific, goal-directed therapy, allowing for its safe implementation in patients with pulmonary hypertension secondary to left heart disease.

Correlation between trans and intra-thoracic impedance and conductance in patients with chronic heart failure.

AIMS: In chronic heart failure, changes of intra-thoracic impedance (Z0IT) may suggest impending pulmonary congestion; a similar result has been found by measuring trans-thoracic conductance (TFCTT = 1/Z0 = 1/kΩ). We assumed that a relationship could exist between Z0IT and TFCTT. METHODS: We collected 140 measurements from 70 patients carrying an implantable cardioverter-defibrillator/cardiac resynchronization device with the CareLink function (71 ± 9 years, New York Heart Association (NYHA) 2.4 ± 0.9, ejection fraction 31 ± 8%, optimal treatment); they were studied during system alarms and after appropriate treatment (diuretics and/or vasodilators, n = 42) or during clinical stability and at the time of a system alarm (n = 28); correspondent BNP values were obtained. We related Z0IT obtained by the device, with TFCTT obtained with a commercial system. RESULTS: A strong relationship was found between Z0IT and TFCTT. Changes in the variables after treatment or during worsening conditions were of the same direction and order of magnitude, and were related to BNP levels obtained simultaneously. CONCLUSIONS: Trans-thoracic conductance, similarly to intra-thoracic impedance, may noninvasively point to pulmonary congestion and be useful in patients not carrying an implanted device. The possibility of remotely obtaining this variable should be evaluated for the telemonitoring of heart failure patients.

Subperitoneal extension of disease processes between the chest, abdomen, and the pelvis.

The subserous space is a large, anatomically continuous potential space that interconnects the chest, abdomen, and pelvis. The subserous space is formed from areolar and adipose tissue, and contains branches of the vascular, lymphatic, and nervous systems. As such, it provides one large continuous space in which many disease processes can spread between the chest, abdomen, and the pelvis.

Reduced thoracic fluid content in early-stage primary biliary cirrhosis that associates with impaired cardiac inotropy.

Primary biliary cirrhosis (PBC) is a chronic liver disease characterized by cholestasis. Recent MRI studies have confirmed the presence of cardiac abnormalities in noncirrhotic PBC patients. However, cardiorespiratory consequences of these abnormalities have not been explored. Thoracic fluid content (TFC) is a noninvasive bioelectrical impedance measure of the electrical conductivity of the chest cavity. We explored TFC and its relationship with cardiac contractility parameters in early-stage PBC patients, compared with chronic liver disease and community controls. TFC was measured in early-stage PBC (noncirrhotic; n = 78), nonalcoholic fatty liver disease (n = 23), and primary sclerosing cholangitis (n = 18) and in a community control population (n = 78). Myocardial contractility was measured as index of contractility, acceleration index, cardiac index, stroke index, left ventricular ejection time, and left ventricular work index. We also measured total arterial compliance and the Heather Index (HI; cardiac inotropy). The PBC group had significantly lower TFC compared with controls and the chronic liver disease groups (P < 0.0001). There was an association between increasing TFC and markers of cardiac function (cardiac index, stroke index, end-diastolic index, index of contractility, and acceleration index), together with indicators of cardiac inotropy and total arterial compliance. Multivariate analysis confirmed that the only parameter that independently associated with TFC was the marker of cardiac inotropy HI (P = 0.037; ß 0.5). This study has confirmed that TFC is reduced in those with PBC, that this is specific to PBC, and that it associates independently with markers of cardiac inotropy.

Comparative lung function performance of stroke survivors and age-matched and sex-matched controls.

BACKGROUND AND PURPOSE: Reduced endurance and excessive fatigue in stroke survivors (SS) during exercise may be linked to impairment of lung function and breathing mechanics, but little is known about lung function of SS. The purpose of this study is to determine lung function (forced expiratory volume in 1 second [FEV1], forced vital capacity [FVC], FEV1 /FVC ratio and peak expiratory flow [PEF]) and influence of anthropometrics on lung function in SS compared with healthy controls (CG). METHODS: In this case-control, cross-sectional study, we recruited 70 participants (42 males, 28 females), comprising 35 SS and 35 CG (range 34-73 years). Anthropometrics were measured using standard instruments and procedure. Chest excursion was measured at the axilla, xiphoid and lower costal levels. Lung function indices were measured using a micro-computerized spirometer. Ethical approval was obtained from the Ethics and Research Committee of Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria. RESULTS/FINDINGS: Compared with the CG, the SS had significantly lower values for FEV1 (1.99 ± 0.66 vs. 2.36 ± 0.45 L, p = 0.004), FVC (2.55 ± 0.70 vs. 2.90 ± 0.54 L, p = 0.014), PEF (3.88 ± 1.38 vs. 5.24 ± 1.30 L second(-1) , p = 0.001) and chest excursion (3.0 ± 0.71 vs. 3.5 ± 0.91 cm, p = 0.018). Correlations between chest excursion, FEV1 , FVC and PEF were not significant (p > 0.05). DISCUSSION: The weakness of respiratory muscles associated with stroke may have contributed to decreases in lung function observed. There was a significant reduction in chest excursion of SS compared with CG. Chest excursion has been used as an indicator of respiratory muscle function because the range of motion of the thorax serves the respiration. Movements of the thorax influence the content of the thorax cavity, leading to alterations in lung volumes. IMPLICATIONS FOR PHYSIOTHERAPY PRACTICE: Stroke survivors have lower lung function when compared with CG; this has implications for clinicians in stroke rehabilitation, underscoring the importance for inclusion of interventions to improve lung function.

[Videothoracoscopic costal pleurectomy by primary and secondary spontaneous pneumothorax].

The aim of the study was to assess the effectiveness of videothoracoscopic (VATS) costal pleurectomy in patients with primary and secondary spontaneous pneumothorax (SP). 136 patients were selected for the retrospective study. Among them 114 were men, the rest 22 - women with a mean age of 29.3 years (range 16 to 37 years). 123 patients had primary SP; 13 patients were diagnosed with interstitial lung disease and secondary SP. The follow-up time after surgery was minimally 3 years. The duration of the postoperative thoracic draining was 2.1 days for patients with primary SP and 3.4 days for those with the secondary SP. The length of the ICU stay was 1.1 and 1.2 days respectively. The overall complication rate was 9% for patients with primary SP and 47% for patients with secondary SP; the recurrence rate was 1 and 23%, respectively. Thus, marked satisfactory immediate and long-term outcomes among patients with primary SP, the VATS pleurectomy can not be considered the method of choice for patients with secondary SP, cause by interstitial lung disease.

Effect of changes in intrathoracic pressure on cardiac function at rest and during moderate exercise in health and heart failure.

This study investigated the effect of changes in inspiratory intrathoracic pressure on stroke volume at rest and during moderate exercise in patients with heart failure and reduced ejection fraction (HFREF) as well as healthy individuals. Stroke volume was obtained by echocardiography during 2 min of spontaneous breathing (S), two progressive levels of inspiratory unloading (UL1 and UL2) using a ventilator, and two progressive levels of inspiratory loading using resistors in 11 patients with HFREF (61 ± 9 years old; ejection fraction 32 ± 4%; NYHA class I-II) and 11 age-matched healthy individuals at rest and during exercise at 60% of maximal aerobic capacity on a semi-recumbent cycle ergometer. At rest, inspiratory unloading progressively decreased stroke volume index (SVI; S, 35.2 ± 5.4 ml m(-2); UL1, 33.3 ± 5.1 ml m(-2); and UL2, 32.2 ± 4.4 ml m(-2)) in healthy individuals, while it increased SVI (S, 31.4 ± 4.6 ml m(-2); UL1, 32.0 ± 5.9 ml m(-2); and UL2, 34.0 ± 7.2 ml m(-2)) in patients with HFREF (P = 0.04). During moderate exercise, inspiratory unloading decreased SVI in a similar manner (S, 43.9 ± 7.1 ml m(-2); UL1, 40.7 ± 4.7 ml m(-2); and UL2, 39.9 ± 3.7 ml m(-1)) in healthy individuals, while it increased SVI (S, 40.8 ± 6.5 ml m(-2); UL1, 42.8 ± 6.9 ml m(-2); and UL2, 44.1 ± 4. ml m(-2)) in patients with HFREF (P = 0.02). Inspiratory loading did not significantly change SVI at rest or during moderate exercise in both groups. It is concluded that inspiratory unloading improved SVI at rest and during moderate exercise in patients with HFREF, possibly due to a reduction in left ventricular afterload.

[Computerized modelling of operation (CMO) before thoracoplasty]. / Thoraco-myoplastica mutéteink számítógépes modellezése és tervezése.

INTRODUCTION: Thoraco-myoplasty (TMP) has proven to be the only successful method of treatment for severe cases of chronic pyothorax (CPT). Great loss of muscle tissue and permanent bone-structure defects with severe functional damage can be caused by this method. The aim of the applied CMO was to prevent additional loss of muscle function. Preoperative evaluation of spiral CT scan 3-dimensional imaging provided a significant aid in decreasing adverse effects of the TMP. MATERIALS AND METHOD: Between 1990 and 2010, TMP was applied in 85 patients, whose CPT came from several different origins. CLINICAL DATA: average age: 62.7; mortality: 4.8%. Tissue and function preserving TMP was achieved following open treatment after thoracic fenestration in 76 cases, and drainage with continuous suction was performed in 9 patients prior to this. In our department TMP with computerized modeling was introduced as the definitive treatment of CPT in 2006, since then it has been applied in 8 patients. RESULTS: The number and length of the ribs to be resected can be anticipated applying spiral CT imaging. Furthermore, accurate volume measurement of the empyema cavity and rotatable muscles (pectoral major and latissimus dorsal) faciliatates elimination of the primary defect during surgery. CONCLUSION: Therefore, we believe that CMO can provide significant aid for surgeons to reduce the negative effects caused by muscle trauma and the structural changes in the thoracic wall.

Changes in cardiac pumping efficiency and intra-thoracic organ volume during negative pressure wound therapy of sternotomy wounds, assessment using magnetic resonance imaging.

Knowledge on the effects of negative pressure wound therapy (NPWT) on the intra-thoracic organs is limited. The present study was performed to investigate the effects of NPWT on the volume of the intra-thoracic organs, using magnetic resonance imaging (MRI), in a porcine sternotomy wound model. Six pigs underwent median sternotomy followed by NPWT at -75, -125 and -175 mmHg. Six pigs were not sternotomised. MR images covering the thorax and heart were acquired. The volumes of the thoracic cavity, lungs, wound fluid and heart were then determined. The volumes of the thoracic cavity and intra-thoracic organs increased after sternotomy and decreased upon NPWT application. The total heart volume variation, which is a measure of cardiac pumping efficiency, was higher after sternotomy and decreased during NPWT. NPWT did not result in the evacuation of wound fluid from the bottom of the wound. NPWT largely closes and restores the thoracic cavity. Cardiac pumping efficiency returns to pre-sternotomy levels during NPWT. This may contribute to the clinical benefits of NPWT over open-chest care, including the stabilizing effects and the reduced need for mechanical ventilation.

Computational model of rib movement and its application in studying the effects of age-related thoracic cage calcification on respiratory system.

A 3D finite element model of rib cage movement is developed and used to study the role of age-related costal cartilage and sternocostal joint calcification, as well as respiratory muscle weakness on the 'bucket-handle' movement of human rib. The volume displacement of the rib cage is related to changes in its circumference using an empirical equation presented by Agostoni et al. (1965, J Appl Physiol, 20:1179-1186). A systematic study is carried out to quantify the role of costal cartilage, sternocostal joint calcification and muscle weakness on the volume displacement of the rib cage. The results provide insight into some of the mechanisms underlying age-related changes in the respiratory system.

Late outcome of surgical treatment of the non-specific neurogenic thoracic outlet syndrome.

OBJECTIVE: Despite the relatively high incidence of the thoracic outlet syndrome, diagnostic criteria, role of surgery and optimal operative approach remain controversial. The main goal of the current study is to determine the long-term outcome of operative treatment of a series of patients with non-specific neurogenic thoracic outlet syndrome. METHODS: A retrospective study of a consecutive group of patients with thoracic outlet syndrome was carried out. The indications for surgery relied on clinical examination. Patients with diffuse pain were excluded. In all cases, the supraclavicular approach was used. Main outcome measures were neurological status and subjective complains. RESULTS: Nineteen patients have been operated over a period of 5 years. Total number of surgeries was 23. Pain and paresthesia on exertion were the leading symptoms in all cases. The causes of thoracic outlet syndrome were fibromuscular compression in 43.5%, cervical rib alone or in combination with a fibromuscular component in 30.4% and the first rib in 26.1%. The average follow-up was 36.3 months. In 91.7%, improvement of at least 50% was observed; 20.8% of the patients were completely symptom-free, and in 25%, the improvement was 90%. Recovery of the pre-operative motor weakness was recorded in 66.6%. The mortality and the permanent morbidity rates of the procedure were 0%. DISCUSSION: Operative decompression of the brachial plexus via the supraclavicular approach in patients with non-specific neurogenic thoracic outlet syndrome is a safe procedure that leads to a significant neurological improvement and amelioration of complains. The indication for surgery should be based chiefly on the neurological and clinical findings.

Spine deformities in rare congenital syndromes: clinical issues.

STUDY DESIGN: A focused review of the literature with regard to the important system abnormalities of patients with spinal deformities associated with exotic congenital syndromes with additional data from the author's own experience in assessment of patients with rare syndromes treated for thoracic insufficiency syndrome. OBJECTIVES: The objectives of this study are to emphasize important medical considerations that influence the choice of surgical treatment of spinal deformity in patients with exotic congenital syndromes and point out preoperative strategies that reduce treatment morbidity and mortality of these patients. SUMMARY OF BACKGROUND DATA: Individual experience is limited in the treatment of spine abnormality in rare exotic syndromes and the medical aspects of these syndromes that may impact spinal treatment are seldom discussed in detail in the orthopedic literature. For a successful outcome in the treatment of spinal deformity in these unique patients, a working knowledge of the unique pitfalls in their medical care is necessary in order to avoid morbidity and mortality during their treatment. METHODS: The literature was reviewed for 6 exotic congenital syndromes with known or unreported spinal abnormalities and the author's personal 22-years experience of the treatment of thoracic insufficiency syndrome in the relevant congenital syndromes was summarized. RESULTS: Children with Marfan syndrome and spinal deformity may have serious cardiac abnormalities. Spontaneous dissection of the aortic root is a clear danger and patients should be monitored by serial echocardiograms. Prophylactic cardiac surgery may be necessary before spinal surgery is to be performed. Patients with Jeune syndrome have a high rate of proximal cervical stenosis and should undergo screening with cervical spine films at birth. Significant stenosis or instability may require decompression and cervical-occipital fusion. Arthrogryposis may be associated with a severe scoliosis and jaw contracture may make intubation difficult. Larsen syndrome may have early onset scoliosis that is very rigid and requires early intervention. Cervical kyphosis and subluxation may be lethal in these patients and screening radiographs are important. Upper airway abnormalities are an anesthesia concern. Jarcho-Levin syndrome is a thoracic volume depletion deformity due to shortness of the thorax, either a spondylocostal dysostosis variant or spondylothoracic dysplasia. The former has a chaotic congenital scoliosis with varied combination of missing and fused ribs. Although spondylocostal dysostosis has a benign reputation in the literature for respiratory complications, respiratory insufficiency is nevertheless common and 1 death is known from respiratory failure. Spondylothoracic dysplasia seldom has significant scoliosis, but has a mortality rate approaching 50% from respiratory complications due to thoracic insufficiency syndrome. In spite of severe restrictive respiratory disease, adult survivors of spondylothoracic dysplasia appear to do well clinically for unknown reasons. Cerebrocostomandibular syndrome has scoliosis, micrognathia, and thoracic insufficiency syndrome, due to an "implosion" deformity of the thorax from congenital pseudarthrosis of the posterior ribs. CONCLUSION: For optimal patient care, it is necessary to have a clear understanding of exotic congenital syndromes and how they may impact on both the presentation of spinal deformity and the response to treatment, as well as how they may introduce additional morbidity into standard treatment plans. It is clear that with this understanding that preoperative strategies can be employed to enhance the safety of spinal treatment for these unique children.

Bilateral pneumothoraces, pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum, and subcutaneous emphysema after thoracoscopic anterior fracture stabilization.

STUDY DESIGN: Case report and clinical discussion. OBJECTIVE: A rare case of air passage into multiple body compartments after thoracoscopic minimally invasive spine surgery is described. SUMMARY OF BACKGROUND DATA: In recent years, there is growing interest in thoracoscopic minimally invasive spine surgery for the treatment of thoracic and lumbar spine fractures. Severe complications due to the operative procedure are rare. METHODS: We present a case of a 73-year-old woman who developed bilateral pneumothoraces, pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum, and subcutaneous emphysema after thoracoscopic anterior stabilization of a Th12 fracture. RESULTS: The operative procedure was completed without any obvious intraoperative complications. Routine made postoperative radiograph of the chest revealed a pneumothorax on the right side, bilateral subphrenic free air, and bilateral supraclavicular air. Subsequently, a CT scan showed bilateral pneumothoraces, pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum and a supraclavicular subcutaneous emphysema. Bronchoscopy, esophagogastroduodenoscopy, and laryngoscopy showed no hollow organ injury or any other pathologic changes. Intraabdominal free air and pneumothoraces could not be detected on thoracic radiographs after 2 days. The patient remained cardiopulmonary stable throughout the hospital course. CONCLUSION: This report documents a rare case of air passage into multiple body compartments after thoracoscopic-assisted treatment of a spinal fracture, which has not yet been described previously. After exclusion of a tracheo-bronchial and hollow organ injury the process was self-limiting. To avoid this complication, special care should be taken to evacuate all intrathoracal air at the end of the endoscopic procedure.