Quantification of eccrine sweat glands with acetylcholine sweat-spot test and anatomical redistribution of sweating after T2-T3 thoracoscopic sympathicolysis.

BACKGROUND: In this study, patients treated by thoracoscopic sympathicolysis for palmar hyperhidrosis were evaluated to determine the number and response of sweat glands to intradermal acetylcholine stimulus. METHODS: A total of 30 patients were included in the study. Group A consisted of 10 patients with palmar hyperhidrosis who underwent thoracoscopic sympathicolysis in October 2005, and group B consisted of 20 patients who underwent surgery during the years 1999, 2000, and 2001. The study procedure involved applying iodine alcohol to the palm and then intradermally injecting 0.1 ml 1% acetylcholine. This activated the sweat glands, which were then photographed and counted. The study procedure was performed prospectively over different periods in group A and retrospectively in group B. RESULTS: In group A, the mean number of glands activated 1, 3, 6, and 12 months after surgery were 41, 174.20, 522.8, and 747.2, respectively; this gradual increase was statistically significant over the first 6 months (p = 0.004) but not between months 6 and 12 (p = 0.255). The trend towards an increasing number of active glands occurred in both groups, with a mean of 1369.8 active glands in group B compared to 747.2 (p = 0.095) in group A after 12 months. CONCLUSION: It is well-known that Cannon's law of denervation (1939) is not applicable to the sweat glands, that is, there is no hyperactivation following intradermal acetylcholine stimulation. However, some response, which increased over the first 6 months following surgery, was observed in our study. Nevertheless, this activation is subsequently self-limiting, resulting in no gland atrophy, and reinnervation occurs without patient awareness.

Spontaneous pneumomediastinum: 41 cases.

OBJECTIVE: Spontaneous pneumomediastinum is characterized by the presence of interstitial air in the mediastinum without any apparent precipitating factor. The purpose of this study is to review and discuss our experience with this condition. METHODS: A descriptive, retrospective study of 41 cases--34 men (83%) and 7 women (17%)--treated at our hospital for spontaneous pneumomediastinum from January 1990 through June 2006. RESULTS: The mean age of the patients was 21 years (range, 14-35 years). Notably, 22% of patients had a prior history of asthma. No precipitating factor was identified in 51% of cases while onset was associated with physical effort in 12%. Chest pain (85%) and dyspnea (49%) were the most common symptoms. Subcutaneous emphysema, which presented in 71% of patients, was the most common sign. Pneumomediastinum was diagnosed by plain chest radiography in all cases. In certain cases, a computed tomography scan of the chest, contrast-enhanced swallow, or bronchoscopy was performed. All patients were admitted to the hospital with good progress and no instances of morbidity or mortality. Treatment included analgesia, rest, and/or initial oxygen therapy. The mean length of hospital stay was 5 days (range, 1-9 days) with only one case of early recurrence, which was resolved satisfactorily. CONCLUSIONS: Spontaneous pneumomediastinum is a benign process primarily affecting young men. Despite its low incidence, spontaneous pneumomediastinum should be considered in the differential diagnosis of acute chest pain because it requires a high index of suspicion. Patients with spontaneous pneumomediastinum respond well to medical treatment, with no recurrence in the great majority of cases.

An assessment of anxiety in patients with primary hyperhidrosis before and after endoscopic thoracic sympathicolysis.

OBJECTIVE: Endoscopic bilateral thoracic sympathicolysis (EBTS) is an effective and minimally invasive procedure used for patients with primary hyperhidrosis. The purpose of this study was to examine anxiety levels using standardized psychometric tools in hyperhidrosis patients before and after EBTS. METHODS: A total of 106 patients diagnosed with hyperhidrosis who underwent EBTS were asked to fill out a questionnaire before and 12 months after the procedure that elicited the following information: (a) symptoms associated with hyperhidrosis; (b) the patient's level of anxiety; and (c) the extent to which this anxiety was incapacitating in their daily life. All patients also completed State-Trait Anxiety Inventory (STAI) before and 12 months after the EBTS. RESULTS: Palpitations were reported preoperatively by 40% of patients versus 10% postoperatively, trembling of the hands in 24% versus 8%, facial blushing in 55% versus 11%, headache in 29% versus 9%, and non-specific epigastric pain in 19% versus 7%. Patients reported a marked improvement in the level of anxiety from a mean SD of 2.08+/-1.1 preoperatively versus 0.39+/-0.67 postoperatively (p<0.001), and the social impact (debilitating) of primary hyperhidrosis before and after surgery also showed significant improvement (p<0.001). The results of STAI showed significant improvement in the levels of anxiety after surgery compared with the preoperative levels and with established norms (p<0.001). CONCLUSIONS: Patients with primary hyperhidrosis that undergo EBTS presented a decrease in the level of anxiety and associated symptoms.

Uniportal video-assisted thoracoscopic lobectomy versus other video-assisted thoracoscopic lobectomy techniques: a randomized study.

OBJECTIVES: A prospective, randomized study was carried out on patients undergoing lung cancer surgery, with the aim of determining if uniportal video-assisted lobectomy has more favourable postoperative outcomes than other video-assisted thoracoscopic lobectomy techniques (Duke approach and Copenhagen approach). METHODS: Patients were randomly assigned to two groups; uniportal video-assisted lobectomy (Group A; n = 51) and other video-assisted thoracoscopic lobectomy techniques (Group B; n = 55). The primary outcome measures were: postoperative pain (analogue visual scale) and supplementary doses of analgesics (morphine, milligrams); the secondary outcome measures were: the delay in removing the paravertebral catheter and the chest drain, the duration of the postoperative hospital stay, postoperative complications and the operative or 30-day mortality. We assessed postoperative pain during the first 3 days to identify possible differences coinciding with paravertebral catheter removal and with the start of mobilization, and we evaluated the type of resection, R0/R1 (a very important factor in assessing postoperative pain). All continuous data were evaluated for normality, and analysed with the Mann-Whitney U-tests or t-tests. Categorical data were analysed by Fisher's exact test. RESULTS: One hundred and six lobectomies were completed. Both groups were comparable with respect to different clinical parameters (age, clinical stage and comorbidity), preoperative and pathological variables. The median visual analogue pain score in the first 3 days did not show statistically significant differences (respectively, P = 0.58, P = 0.64, P = 0.85). Likewise, the median morphine use in the first 3 days did not show statistically significant differences (respectively, P = 0.72, P = 0.81, P = 0.64). There was no difference in timing to remove the paravertebral catheter (P = 0.82) and the chest drain (P = 0.65) and the duration of the postoperative hospital stay (P = 0.62). There was no difference in postoperative complications (one reoperation for bleeding in Group B, P = 0.24). There was no operative or 30-day mortality in either group. CONCLUSIONS: Uniportal video-assisted thoracoscopic lobectomy does not present better postoperative outcomes than other video-assisted thoracoscopic lobectomy techniques.

Uniportal right upper video-assisted thoracoscopic surgery lobectomy: safe and feasible.

Uniportal video-assisted thoracoscopic surgery (VATS) lobectomy is now well established and performed all around the world. We are going to share the surgical technique for uniportal VATS right upper lobectomy based on our experience. A 62-year-old patient underwent Uniportal VATS right upper lobectomy for a primary non-small cell lung cancer (NSCLC). Our patient had no perioperative complications and was then discharged to his home on postoperative day 4. The patient's pain was managed with a paravertebral catheter during the first 48 hours and then with oral analgesics. Pathology report: well-differentiated adenocarcinoma; the size of the tumour was 1 cm × 0.8 cm × 1 cm; all margins were negative for residual tumour. The patient did not require adjuvant radiation or chemotherapy. Uniportal VATS lobectomy is a safe and effective procedure providing a favourable clinical outcome in the patient.

[Prognostic factors in chest traumas: a prospective study of 500 patients]. / Factores pronóstico del traumatismo torácico: estudio prospectivo de 500 pacientes.

OBJECTIVE: Identify the factors of greatest impact in patients with chest trauma. PATIENTS AND METHODS: prospective study of 500 patients (425 men and 75 women) with chest trauma treated between January 2006 and December 2008. The parameters assessed include the degree of trauma, the abbreviated injury scale (AIS), the injury severity score (ISS), pre-hospital intubation, duration of mechanical ventilation, stay in the intensive care unit (ICU), number of rib fractures, presence of pulmonary contusion, haemothorax and cardio-pulmonary effects. RESULTS: The presence of polytrauma, the number of rib fractures, the presence of flail chest, pulmonary contusion, the delay in mechanical ventilation and age were shown to be effective markers of severity. CONCLUSIONS: Thoracic injuries have a number of indicators of severity. The mortality risk is associated with an ISS >25, the presence of 3 or more rib fractures with flail chest, pulmonary contusion, the development of ARDS, and with an age >55 years.

Pneumomediastinum: is this really a benign entity? When it can be considered as spontaneous? Our experience in 47 adult patients.

OBJECTIVE: Spontaneous pneumomediastinum is uncommon and is traditionally considered a benign, self-limited disorder that usually occurs in young adults without any apparent precipitating factor or disease. The purpose of this study is to present 47 new cases because of their different clinical behaviours. METHODS: A descriptive, retrospective case series was conducted to identify adult patients with spontaneous pneumomediastinum who were diagnosed and treated in a single institution between 2000 and 2008. RESULTS: Forty-seven patients were identified, including 33 men and 14 women with a mean age of 27.3 years (range, 16-42 years). Acute-onset chest pain was the predominant symptom at presentation (59.5%); subcutaneous emphysema was the most common sign (42.9%). The most common predisposing factor was consumption of illegal drug (cocaine): it was not a regular and long-term abuse but an occasional trend, coinciding few hours before presenting symptoms (55%). Notably, in one case, a bad outcome with mediastinal shift and important tracheal compression necessitated a right thoracotomy to open the mediastinal pleura. CONCLUSIONS: (1) It is known that occasional consumption of cocaine causes diffuse alveolar damage, haemorrhage, etc. The cause-effect relationship consumption-appearance in a few hours of spontaneous pneumomediastinum leads us to appreciate this form of consumption as a causal factor rather than a predisposing/precipitating factor as it appears in the literature on the topic. (2) Spontaneous pneumomediastinum is considered a benign disorder but, as shown by our series, a bad outcome may represent an immediate life-threatening condition, forcing an invasive manoeuvre. We always recommend performing a chest CT scan on admission to predict the evolution.

Localized (solitary) fibrous tumors of the pleura: an analysis of 15 patients.

BACKGROUND: Localized fibrous tumors of the pleura (LFTPs) are rare neoplasms, which are considered to originate from submesothelial connective tissue. The aim of this article is to present 15 new cases because of their different clinical behaviors and to discuss the treatment of choice of such neoplasms. METHODS: The records of 15 consecutive patients with LFTP operated at our Institution between 1995 and 2006 were retrospectively reviewed. Diagnostic procedures, clinical courses, and outcomes of these patients were studied. Total excision through a thoracotomy was performed in all patients. Neoplasms were considered to be malignant if one or more of the following histologic features were present: increasing mitotic activity; high cellularity with crowding and overlapping of nuclei; necrosis; and pleomorphism. RESULTS: No operative mortality was reported. The mean follow-up time was 76 months. Malignant transformation was seen in 1 patient 26 months after resection of a benign tumor. Six cases were pathologically considered to be malignant: 2 patients developed local recurrence. One of these underwent redo-surgery and required pneumonectomy; in the other one surgery is not indicated because at the time of diagnosis the patient was 85 years. Currently, all patients are alive and 13 disease-free. CONCLUSIONS: For histologically benign tumors, because of the risk of recurrence and malignant transformation, complete surgical resection is indicated and long-term follow-up is recommended in all patients. For malignant cases, complete surgical resection may be insufficient for the cure: further study should be performed to identify reliable prognostic factors to indicate and evaluate the effectiveness of systemic treatment.

[Iatrogenic tracheal rupture after endotracheal intubation]. / Rotura traqueal yatrogénica por intubación orotraqueal.

Tracheobronchial rupture after tracheal intubation is rare in clinical practice. Possible contributory factors are multiple vigorous attempts at intubation, overinflation of the cuff, anatomic alterations, and predisposing individual factors. These lesions can be detected by bronchoscopy, which is the most effective method to confirm the diagnosis and determine the exact location and extent of the tear. We report the case of a woman with membranous tracheal rupture after endotracheal intubation. Subcutaneous emphysema, pneumomediastinum and bilateral pneumothorax were noted after extubation. The diagnosis was confirmed by fiberoptic bronchoscopy and computed tomography scan, and the patient required emergency surgical repair.

Factores pronóstico del traumatismo torácico: estudio prospectivo de 500 pacientes / Prognostic factors in chest traumas: A prospective study of 500 patients

Objetivo Identificar los factores pronóstico de mayor impacto en el paciente con traumatismo torácico. Método Estudio prospectivo de 500 pacientes (425 hombres y 75 mujeres) con traumatismo torácico atendidos entre enero de 2006 y diciembre de 2008. Los parámetros valorados incluyen el grado del traumatismo, la abbreviate injury scale, el injury severity score, la intubación prehospitalaria, la duración de la ventilación mecánica, la estancia en unidad de cuidados intensivos, el número de fracturas costales, la presencia de contusión pulmonar, hemotórax y repercusión cardiopulmonar. Resultados La presencia de politraumatismo, el número de fracturas costales, la presencia de volet, la contusión pulmonar, el retraso en la ventilación mecánica y la edad se han demostrado marcadores eficaces de gravedad. Conclusiones Los traumatismos torácicos tienen una serie de indicadores de gravedad: el riesgo de mortalidad se asocia con un injury severity score >25, la presencia de 3 o más fracturas costales con volet costal, contusión pulmonar, el desarrollo de ARDS y con una edad >55 años (AU)

Objective Identify the factors of greatest impact in patients with chest trauma. Patients and methods prospective study of 500 patients (425 men and 75 women) with chest trauma treated between January 2006 and December 2008. The parameters assessed include the degree of trauma, the abbreviated injury scale (AIS), the injury severity score (ISS), pre-hospital intubation, duration of mechanical ventilation, stay in the intensive care unit (ICU), number of rib fractures, presence of pulmonary contusion, haemothorax and cardio-pulmonary effects. Results The presence of polytrauma, the number of rib fractures, the presence of flail chest, pulmonary contusion, the delay in mechanical ventilation and age were shown to be effective markers of severity. Conclusions Thoracic injuries have a number of indicators of severity. The mortality risk is associated with an ISS >25, the presence of 3 or more rib fractures with flail chest, pulmonary contusion, the development of ARDS, and with an age >55 years (AU)

Rotura traqueal yatrogénica por intubación orotraqueal / Iatrogenic tracheal rupture after endotracheal intubation

Las laceraciones traqueobronquiales traumáticas postintubación son una complicación clínica poco frecuente en la práctica diaria. Se han relacionado con intentos repetitivos de intubación e hiperinsuflación del balón, así como con alteraciones anatómicas y factores individuales que puedan predisponerla. El diagnóstico se obtiene, actualmente, mediante la endoscopia respiratoria, ya que informa sobre su localización y la extensión lesional. Presentamos el caso de una paciente con laceración de la cara posterior traqueal secundaria a intubación endotraqueal que comenzó con enfisema mediastínico subcutáneo y neumotórax bilateral en el postoperatorio inmediato. El diagnóstico se realizó mediante fibrobroncoscopia y tomografía computarizada y requirió cirugía traqueal de urgencia (AU)

Tracheobronchial rupture after tracheal intubation is rare in clinical practice. Possible contributory factors are multiple vigorous attempts at intubation, overinflation of the cuff, anatomic alterations, and predisposing individual factors. These lesions can be detected by bronchoscopy, which is the most effec-tive method to confirm the diagnosis and determine the exact location and extent of the tear. We report the case of a woman with membranous tracheal rupture after endotracheal intubation. Subcutaneous emphysema, pneumomediastinum and bilateral pneumothorax were noted after extubation. The diagnosis was confirmed by fiberoptic bronchoscopy and computed tomography scan, and the patient required emergency surgical repair (AU)