Massive hemoptysis caused by a ruptured subclavian artery aneurysm.

We report a case of left subclavian artery aneurysm, which ruptured and penetrated through the left upper lung parenchyma causing massive hemoptysis and a left hemothorax. Through sternothoracotomy, tangential aneurysmorrhaphy under proximal control and left upper pulmonary lobectomy were performed. The patient is doing well after nearly three years of follow-up.

Prevention and management of strictures after hypopharyngocolostomy or esophagocolostomy.

The records of 14 patients who underwent surgical revision for anastomotic strictures after hypopharyngocolostomy or esophagocolostomy were reviewed. The esophageal reconstruction was originally performed for esophageal strictures or resections after corrosive injury in 13 patients and for achalasia in 1. The esophageal substitutes used consisted of right ileocolon in 12 patients and left colon in 2. Routes of colon positioning were substernal in 13 patients and subcutaneous in 1. One-half of all strictures were located at the hypopharynx and the other half at the cervical esophagus. Causes of the strictures were anastomotic leakage in 5 patients, progressive caustic scarring in 4, graft ischemia in 3, combined caustic and tuberculous scar in 1, and technical error in 1. The interval from esophageal reconstruction to the revision was 1 month to 15 years with a median of 7 months. Surgical approaches included cervical incision only in 9 patients, cervical incision plus sternotomy in 3, and cervical incision plus partial resection of sternal manubrium in 2. Revisional procedures consisted of excision of scar with reanastomosis in 12 patients, skin graft in 1, and free jejunal graft in 1. After revision, all but 1 patient had excellent results. On the basis of these experiences we conclude that most strictures after pharyngocolostomy or esophagocolostomy can be surgically corrected after excision of the scar and mobilization of the esophageal substitute through a cervical incision only or a cervical incision plus sternotomy.

Surgery for malignant involvement of the superior vena cava.

This study reviews surgical operations on seven patients with intrathoracic tumors involving the superior vena cava (SVC). Among these patients, five were found to have advanced bronchogenic carcinoma; one was found to have thyroid carcinoma; and another was found to have thymic carcinoma. The incidence of SVC involvement in resectable lung cancer patients at the National Cheng-Kung University Hospital was 5.8% (5/85). Total excision of SVC was done in three patients and three different prostheses (ringed GoreTex, woven Dacron and pericardial tube graft) were interposed. Four patients underwent partial excision and repair: one by direct suture and three by autologous pericardial patch. A temporary SVC-right atrium internal shunt was used in two of these seven patients. The mean time of SVC cross-clamping in five patients was 20 minutes (10-28 minutes), and the mean value of the central venous pressure at the time of SVC cross-clamping was 34 mmHg (18-54 mmHg). There were no operative deaths or neurologic sequels. Venography or computed tomography obtained 7-100 days after surgery demonstrated all but one to be patent. In conclusion, SVC reconstruction with concomitant tumor resection can be performed if a patient fulfills the following criteria: 1) there is no distant metastasis; 2) a radiosensitive or chemotherapy-effective tumor has been ruled out; and 3) total SVC occlusion or prominent collateral circulation should be avoided.

Modified Senning procedures for simple transposition of the great arteries.

From December 1990 to July 1994, 10 infants with simple transposition of the great arteries (TGA) underwent the Senning procedure at National Cheng Kung University Medical College. Their ages ranged from 1 to 8 months (mean, 4.8 +/- 2 months), and their body weight ranged from 3.5 to 7.5 kg (mean, 5.7 +/- 1.2 kg). Four infants were treated with the conventional method by covering the sinoatrial (SA) node with the anterior right atrial flap (group 1). The other six patients had modified procedures, having the suture line across the caval vein, caudal to the SA node (group 2). Three of the group 1 patients experienced junctional rhythm temporarily, another had SA node dysfunction for 1 week postoperatively. In group 2, all patients were in sinus rhythm except one, who returned to sinus rhythm on the second postoperative day. There was one (10%) surgical mortality, a patient in group 1, and one (10%) late mortality, in group 2. The clinical follow-up interval was 6 to 46 months (mean, 28.8 mo). All survivors were in sinus rhythm, and echocardiographic studies demonstrated no difference between the two groups as to conduit obstruction or degree of tricuspid valve regurgitation. In conclusion, in situations that require atrial switch for the correction of TGA, a suture line across the caval vein, caudal to the SA node, may be a useful modification to prevent arrhythmias.

Intrathoracic migration of Kirschner wires.

Two cases of intrathoracic migration of Kirschner wires are reported. Two wires were used to fix a left clavicle fracture in case 1. Two months later, a chest film showed a broken wire migrating into the mediastinum. A chest computed tomogram revealed the Kirschner wire penetrating into the main pulmonary artery. The broken wire was removed through sternothoracotomy after a pericardiotomy. In case 2, repeated blood-tinged sputum was experienced 5 years and 6 months after Kirschner wire fixation of 2 left clavicle fractures. Chest film showed the migrated wire located in the right thorax. The wire was removed through right thoracotomy. In both cases, the foreign bodies were successfully removed and vascular and pulmonary repair were performed without morbidity.

Bronchial rupture caused by blunt chest injury.

We have surgically treated six patients with bronchial rupture caused by blunt chest injury in the past 5 years. All injuries resulted from traffic accidents, except in one patient who was hit by a crane. Clinical manifestations included chest pain (n = 6), subcutaneous emphysema (n = 4), and dyspnea (n = 6). Roentgenographic findings were tension (n = 3) or nontension (n = 3) pneumothorax, subcutaneous emphysema (n = 4), pneumomediastinum (n = 3), deep cervical emphysema (n = 5), and delayed collapse of the affected lung (n = 3). Three patients had associated injuries: right clavicle and rib fractures in the first; right humeral, scapular, and multiple rib fractures and left sternoclavicular joint dislocation in the second; and left clavicle fracture in the third. These six patients all underwent immediate tube thoracostomy and then bronchoplasty. Bronchoplasty was performed within 3 days in four patients and on days 16 and 30, respectively, in the other two patients. The affected lung demonstrated full expansion in all patients immediately after bronchoplasty. Follow-up bronchoscopy showed good patency of all bronchi.

Serum IgE, skin and radioallergosorbent tests for house dust and mites in asthmatic children.

Thirty asthmatic children were given an intradermal skin test, total IgE measurements and the radioallergosorbent test (RAST) against house dust and house dust mites (Dermatophagoides pteronyssinus and Dermatophagoides farinae). Results of the intradermal skin test and RAST were highly positive with overall agreement in 95.6%. The correlation coefficient between the total IgE and the RAST to house dust was 0.35 (p less than 0.05). There was no significant difference between the total IgE and the RAST to D. pteronyssinus and D. farinae (p greater than 0.05). The highly significant correlation coefficient between house dust and house dust mites (D. farinae, p less than 0.0001; D. pteronyssinus, p less than 0.00001) was determined by RAST. House dust has been found to be the most important allergen in children in Taiwan. The role of mites as a possible allergen in house dust also showed a highly significant correlation in our study.

Congenital tuberculosis: a case report.

Congenital tuberculosis is a rare disease, difficult to be correctly diagnosed from clinical manifestations alone without maternal tuberculous history. In this article we report a neonate who exhibited abdominal distension and bloody diarrhea simulating neonatal sepsis and necrotizing enterocolitis. Exploratory laparatomy was performed for the markedly distended abdomen and deteriorated condition. Calcified lymph nodes over mesentery and spleen were found, and biopsy was done to show caseous tubercles. However, this neonate deteriorated rapidly and died one day after operation. Autopsy revealed generalized discrete miliary tubercles over the lungs, liver, spleen, pancreas, adrenal glands, thyroid and lymph nodes.