Clinical Significance of Fibrinogen Degradation Product Among Traumatized Patients.

OBJECTIVE: We retrospectively analyzed trauma patients who were transported by a physician-staffed helicopter (doctor helicopter) to investigate the clinical significance of the fibrinogen degradation product (FDP) level on arrival. METHODS: From February 2011 to July 2016, a medical chart review was retrospectively performed for all patients with trauma who were transported by the doctor helicopter. The subjects were divided into 2 groups: a survival group and a fatal group. RESULTS: There were 135 patients in the survival group and 16 in the fatal group. The ratio of head injury, value of Injury Severity Score (ISS), and level of FDP in the fatal group were significantly greater than in the survival group. The average Glasgow Coma Scale and systolic blood pressure in the fatal group were significantly smaller than in the survival group. The FDP level at arrival was positively associated with the ISS (R = 0.74, P < .0001). After excluding subjects with shock, unconsciousness, and head injury, the FDP level was still positively associated with the ISS (R = 0.60, P < .0001). CONCLUSION: Therefore, the FDP level may be a useful biochemical parameter for the initial evaluation of the severity of trauma, even in blunt trauma patients without head injury or with stable vital signs.

[Wide resection of chest wall for intramuscular lipoma in serratus anterior muscle reconstructed by autologous tissue;report of a case].

A 60-years-old man with a right lateral chest wall mass visited our hospital. There was a mass of 50×45 mm on the 5th rib. The mild atypical cells were detected by the percutaneous needle biopsy, and the tumor was resected with the chest wall of which detect was reconstructed with fascia lata and latissimus dorsi muscle cutaneous flap. Pathological diagnosis was lipoma in the serratus anterior muscle. The postoperative course was uneventful without paradoxical respiration and surgical site infection. Since intramuscular lipoma is very rare and is reported to have a risk of recurrence, careful observation is necessary.

[Schwannoma of the chest wall showing a bead-like appearance;report of a case].

A 35-year-old man with a chest abnormal shadow was referred to our hospital. Computed tomography(CT) revealed a bead-like shaped mass along the right 7th rib. The lesion appeared to have 2 narrow parts and was divided into 3 round portions. T2-weighted images of the magnetic resonance imaging(MRI) revealed marked hyperintensity in the peripheral portions and nodule-like intermediate signal intensity in one of the central zone of the round portions, which is so-called "target appearance". The bead-like mass with 3 round portions revealed to be a mass of the right 7th intercostal nerve. The tumor was diagnosed as benign schwannoma of mixed Antoni type A and type B histologically.

[Prolonged iatrogenic pneumothorax with refractory hepatic hydrothorax treated successfully with local anesthetic thoracoscopic talc poudrage].

A 64-year-old woman with liver cirrhosis caused by hepatitis C was presented with aggravated dyspnea. She had refractory hepatic hydrothorax, requiring pleural puncture and drainage of approximately 3,000 ml per week. Four days after the last puncture, she consulted the emergency department and chest films revealed right tension pneumothorax. A drainage tube was inserted to her right pleural cavity, but middle and lower lobes were not expanded, and air leaks persisted. We thought that she was in high-risk of infections, like empyema, and needed surgical treatment to close the pulmonary fistula promptly. Considering her poor general condition, we performed local anesthetic thoracoscopic talc poudrage, and air leaks were controlled successfully. Perioperative period was uneventful.

Surgery for secondary spontaneous pneumothorax: risk factors for recurrence and morbidity.

OBJECTIVES: Secondary spontaneous pneumothorax (SSP) is more common in elderly patients; it has high rates of recurrence and mortality, even if surgery is performed. There has been little study on the surgical treatment of SSP. Therefore, we analysed the outcomes of surgical treatment of SSP patients, and investigated the risk factors of recurrence and morbidity. METHODS: We studied 97 consecutive surgical treatments on 94 patients with SSP who had emphysematous changes of lung retrospectively. Emphysematous changes on preoperative computed tomography image were evaluated by the Goddard score, which is a visual scoring system. First, video-assisted thoracoscopic surgery was performed, followed by bullectomy for the responsible lesions. RESULTS: The rate of morbidity was 20.6% and that of mortality was 4.1%. Recurrence rate was 9.3%. By multivariate analysis, a Goddard score≥7 (odds ratio: 8.93, P=0.033) and treatment of bulla without the use of staplers (odds ratio: 11.57, P=0.019) were significant risk factors for morbidity, while pulmonary fibrosis tended to increase the risk of recurrence (hazard ratio: 4.21, P=0.051), and a Goddard score≥7 (hazard ratio: 7.79, P=0.023) was a significant risk factor for recurrence. CONCLUSIONS: Surgical treatment in patients with SSP had favourable results. Treatment in which the base of the bulla cannot be definitely shut off with staplers is associated with increased morbidity. Significant emphysematous change on preoperative computed tomography image and pulmonary fibrosis are predictors of recurrence. Patients with these findings should be investigated in terms of the indications of surgery and additional treatment, not only bullectomy.

Acute empyema with intractable pneumothorax associated with ruptured lung abscess caused by Mycobacterium avium.

Nontuberculous mycobacterial lung disease rarely features pleural involvement. Therapeutic strategies for this situation have not been well established. We present a case of acute empyema with intractable pneumothorax associated with ruptured lung abscess caused by Mycobacterium avium in an immunocompromised patient. Combined treatment that included multidrug antibiotic therapy and nonresectional surgery resulted in a good outcome.

Secondary spontaneous pneumothorax associated with emphysema and ruptured bullae at the azygoesophageal recess.

PURPOSE: With secondary spontaneous pneumothorax (SSP) associated with emphysema, lesions responsible for pneumothorax can be located anywhere along the lung surface. Among such lesions, ruptured bullae at the azygoesophageal recess (AER) have received little attention thus far. METHODS: We conducted a retrospective study of 38 right SSP patients with emphysema who underwent surgery. Among them, we reviewed the clinical characteristics and technical problems of patients with surgically proven ruptured bullae at the AER. RESULTS: Ruptured bullae at the AER were found in 10 of 38 patients. They accounted for 26.3% of all 38 patients and for 66.7% of 15 patients whose bullae at the AER were identified by preoperative computed tomography (CT). On CT, all the bullae were relatively large and oriented in a predominantly vertical axis. At surgery, they were confirmed as white, thin-walled structures originating from the mediastinal part of the apical segment of the right lower lobe. Surgery typically consisted of stapling bullectomy with video-assisted thoracic surgery. Technical problems in surgical treatment included poor mobilization of the base of the bulla and a restricted working space. CONCLUSION: Bullae at the AER are common and possibly lead to rupture. The presence of a bulla at the AER seen by CT can be predictive of rupture. Although the AER is a unique location, video-assisted bullectomy is the method of choice for treating these lesions.

Pleural space sterilization using gentian violet irrigation for postbullectomy empyema associated with artificial material infection.

Postoperative empyema associated with artificial material infection involves several treatment problems. We report the successful treatment of a case of post-bullectomy empyema with a small alveolar fistula that was associated with artificial material infection by Streptococcus viridans. In this case, complete empyema space sterilization was obtained by tube drainage and daily pleural irrigation using 0.1% gentian violet solution. This treatment circumvented the need for invasive surgery, including removal of the infected artificial materials and space-filling and/or collapse procedures. Consequently, gentian violet irrigation may be a useful treatment option in selected cases with complicated thoracic empyema.

Spontaneous pneumothorax and a coexistent azygos lobe.

We present a primary spontaneous pneumothorax involving a possible diagnostic and surgical pitfall. A 25-year-old man with a previously identified azygos lobe was admitted to our hospital because of right primary spontaneous pneumothorax. A preoperative chest X-ray at the onset of the pneumothorax as well as after resolution by tube drainage showed an azygos fissure but no azygos vein. Chest computed tomography revealed the dislocated azygos vein external to the azygos fissure on the mediastinal side of the reexpanded upper lobe. Thoracoscopic bullectomies were uneventfully performed. The azygos arch was found dangling in the free inferior border of the mesoazygos. An azygos vein located in this position can be a potential surgical hazard especially in video-assisted thoracic surgery. This case suggests that the presence of an azygos lobe can be missed on chest X-ray when a pneumothorax occurs in a patient with an azygos lobe.

Anomalous systemic arterial supply to the basal segments of the left lung with two aberrant arteries.

A 30-year-old man was admitted to our hospital because of hemoptysis. Digital subtraction aortography revealed an anomalous systemic artery (10 mm diameter) from the descending thoracic aorta to the basal segments of the left lung. The presence of another smaller aberrant artery from the abdominal aorta was strongly suspected on the basis of aortography. We confirmed the presence of a smaller aberrant artery (3 mm diameter) traversing the pulmonary ligament after thoracotomy. We performed left lower lobectomy with resection of the two aberrant arteries via posterolateral thoracotomy with a favorable postoperative outcome. Although it is rare, the possibility of the presence of several aberrant arteries should be considered in anomalous systemic arterial supply to the basal segment of the left lung. Preoperative identification of aberrant arteries was useful for a safe operative procedure.

Right upper lobe venous drainage posterior to the bronchus intermedius: preoperative identification by computed tomography.

BACKGROUND: Anatomical variations of the pulmonary vessels relevant to pulmonary surgery are of concern to thoracic surgeons. Among such variations, the right upper lobe vein posterior to the bronchus intermedius (UVPBI) has received little attention thus far. METHODS: Chest computed tomographic images and medical records of 725 patients were retrospectively reviewed. The frequency, drainage pattern, diameter, and associated anatomical characteristics of the UVPBI were assessed, and our right thoracotomy cases with the UVPBI were examined. RESULTS: The UVPBI was found in 41 (5.7%) of 725 computed tomography cases, and in 9 (3.9%) of 230 right thoracotomy cases. Three UVPBI drainage sites were observed: (1) the superior pulmonary vein group, 55%; (2) the inferior pulmonary vein group, 41%; and (3) the superior segmental vein group, 4%. The diameter of the UVPBI at the level of the bronchus intermedius ranged from 1 to 7 mm (4.1 +/- 1.6 mm). The diameter of the UVPBI in the superior pulmonary vein group was significantly greater than that in the inferior pulmonary vein group (p < 0.01). The prevalence of a central vein was 43.9% for all UVPBI cases and 15.8% for large UVPBI cases (> or = 5 mm in diameter). Of the 9 right thoracotomy patients, 1 suffered UVPBI injury; this patient's UVPBI was not identified either preoperatively or intraoperatively. CONCLUSIONS: The UVPBI is not as rare as was previously believed. It can be a main drainage route of the right upper lobe. Preoperative identification of this venous variation by computed tomography is useful for safe and accurate surgical procedures.