proposed grading system for post-intubation tracheal stenosis

Tracheal stenosis is still a serious consequence of endotracheal intubation. Previous classification systems are commonly descriptive and are not intended to deal with management approach. The aim of this study was to present a classification system for post intubation tracheal stenosis and evaluate its efficacy in distinguishing critically ill patients who need surgical intervention. This classification system was developed based on size and type of stenosis and associated clinical signs and symptoms. Stenosis was graded based on the results of clinical examination and rigid bronchoscopy. All patients received surgical or conservative treatment based on the judgment of a surgeon experienced in management of post-intubation tracheal stenosis without considering their score. ROC curve analysis was done and cut-off point was established based on the greatest Youden index. Sixty patients were studied. Resection and anastomosis were done for 49 patients. The mean score for all samples was 9.18 [range 8.77-9.45]. Chosen cutoff point was 8.5 and calculated sensitivity and specificity were 89% and 42%, respectively. Positive and negative predictive values were 83.7% and 54.5%, respectively. A reasonable agreement between the estimated score and surgeon's clinical judgment [kappa=0.78] was observed. A statistically significant relationship was observed between scores greater than 8.5 and need for surgical intervention [P= 0.007]. We presented a scoring system for post-intubation and tracheostomy tracheal stenosis using main factors influencing diagnosis and treatment and its efficacy was evaluated prospectively. It seems that this system would be capable of assimilating the treatment interventions and comparing them

Surgical treatment of post-intubation tracheal stenosis

Incidence of post-intubation tracheal stenoses is relatively high in Iran and the majority of tracheal surgeries are performed to treat these strictures. Therefore, it is important to become familiar with the nature of tracheal stenoses and know their treatment methods. Most surgeons learn different methods of tracheal surgery through operating on cases of post-intubation tracheal stenoses and apply these methods for surgical operation of tracheal tumors. We mainly focused on the technique of tracheal surgery, patient selection, and pre-op and post-op equipments required. Other related fields such as anatomy of the trachea, bronchoscopy, imaging, laser therapy and stenting are mentioned when necessary

Results of Surgical treatment for postintubation airway stenosis, in 901 patients

Although resection and anastomosis [RA] is known as most efficient method for treatment of post-intubation airway stenoses, non-resectional methods are being developed and suggested as substitutes for RA. Presenting our experience with sufficient number of patients who underwent resection might be helpful in comparison and selection of various treatment methods. All patients who had been referred to us [Feb 1994 to Jan 2007] underwent bronchoscopy and evaluation of the stricture and function of the larynx. Patients in good general condition whose strictures were operable by RA underwent this operation. Other patients underwent non-resectional treatments. Three types of operations were performed 1] tracheal resection 2] resection of trachea and anterior arch of cricoid 3] resection of trachea and anterior arch of cricoid associated with posterior cricoidotomy and autologous cartilage grafting at the site of cricoidotomy. Surgical results were categorized into good, acceptable and failure. Results were analyzed using SPSS software with Chi-square and Fisher's exact tests. Nine hundred one patients underwent treatment during 13 years out of which, 571 underwent RA [420 men, 151 women, mean age 25.6 yrs]. Types 1, 2 and 3 operations were performed on 451, 88 and 32 patients, respectively. Results were good in 434 [76.10%], acceptable in 79 [13.84%] and failure in 53 [9.29%] patients. Thirteen deaths occurred after resectional treatment and 25 deaths after non-resectional treatments. Single-stage resection and anastomosis is an appropriate treatment for most cases of post-intubation tracheal and laryngotracheal stenoses

[Emergency tracheostomy in patients with postintubation tracheal stenosis; an uncertain and risky practice]

Usually, postintubation tracheal stenosis [PITS] can be diagnosed by history and physical examination. Emergent tracheotomy is performed in some patients who present with severe dyspnea. In our view, dilatation of the stenosis can resolve the patient's acute issues and prevent complications of tracheotomy. In this study, we evaluate the results and complications of emergent tracheotomy compared with dilatation. This retrospective, case-control study performed on patients with postintubation tracheal stenosis in a seven years period. The case group was patients who underwent emergent tracheotomy prior to admission to our center. The control group had not been undergone tracheotomy and the relief of dyspnea was accomplished by rigid bronchoscopy and dilatation. Patients who received elective tracheotomies were excluded from the study. Tracheal resection and anastomosis was performed for all patients who had favorable condition after initial supportive therapy. The variables including length of stenosis, length of resection, duration of hospitalization, subglottic involvement, results of surgery, and unresectability were compared between two groups. Statistical tests were T-test and chi-square. The average follow-up time was 9.8 [1-33 months] in the case group and 10.2 [1-52 months] in the control group. 721 patients [511 male, 210 female] were evaluated, with a mean age of 27.2 years. 104 patients received emergent tracheotomies. Subglottic involvement and unresectability were greater and response to bronchoscopy and dilatation was lower in the case group [P<0.05]. Following factors, age [younger], length of resection and failure in surgery were also higher in the case group, although the difference was not statistically significant. Emergent tracheotomy in these patients in an avoidable procedure which can lead to failure of desired results. In critical cases, severe acute stenosis can be best managed with rigid bronchoscopy and dilatation

Dysphonia and cervicomediastinal mass, very unusual presentation of hydatid cyst

Hydatid disease, still endemic in developing countries, involves the liver and the lungs of the vast majority of cases. We report a very rare presentation of hydatid disease in a 35 year-old man with a cervicomediastinal mass and vocal cord paralysis, suspected of thyroid tumor. Surgery was curative and dysphonia disappeared completely

Conventional giant cell tumor of the rib with pulmonary metastases: a case report and review of literature

We report a 25-year-old female with a giant cell tumor originating from the anterior arc of the rib who presented with bilateral pulmonary metastases. She underwent extensive resection of the thoracic wall, attached right middle lobe and right upper lobe metastases. She was treated with Interferon-alpha-2b [INF] followed by systemic chemotherapy. After 23 months, she had no complaint and no significant disease progression was detected through imaging studies

Fracture and aspiration of tracheostomy tube

Methods of opening the airways like tracheostomy are used to provide appropriate ventilation for patients with upper airway problems. Tracheostomy may be accompanied by some complications. In the present study, we reported a 41- year-old man with progressive dyspnea and cyanosis induced by fracture of tracheostomy tube. He referred to our center and a chest x-ray was obtained showing fracture of tracheostomy tube within trachea. He underwent surgery and fractured tracheostomy was removed/ extracted. A plastic tracheostomy tube was placed for him and he discharged the day after. Fracture and aspiration of tracheostomy tube is a rare complication which requires a prompt and precise management. Patient education regarding the maintenance of tracheostomy tube for prevention of this complication is highly recommended

Presentation of a surgical technique and results in the treatment of lung hydatid cyst

Due to the diversity of surgical techniques and great differences in the incidence of pulmonary hydatid cysts around the world, the most appropriate surgical technique has not yet been substantiated. We presented the results of a single surgical technique in a consecutive group of patients and described the technical details. The study was conducted during an 8-year period on 125 patients with a mean age of 33.1 yrs that were suffering from pulmonary hydatid cysts. The surgical procedure included: thoracotomy, opening the cyst, removing all its contents, removal and suturing the bronchial openings. The pericyst cavity left open into the pleural space. Surgical complications, morbidity and mortality rates were evaluated. In addition, the recurrence rate was assessed post-operatively by periodic chest radiographs. There were a total of 181 cysts in 125 patients; 156[86.2%] cysts were operated via the above-mentioned technique and for 25 cysts due to destruction of parenchyma, lobectomy [n=9] or segmentectomy [n=2] was performed. Complications included prolonged air leakage in 4, persistent pleural effusion in 1 and pulmonary embolism in 1patient. There were five recurrences [2.8%] and 1 death due to pneumonia and sepsis. Thoracotomy, evacuation of the endocyst and closure of the bronchial openings comprise an appropriate surgical technique for the treatment of hydatid cysts of the lung

Medical versus surgical management in patients with bronchiectasis

Recent advancements in the fields of antibiotic therapy, vaccination and general health have decreased the number of surgical interventions for the treatment of bronchiectasis. On the other hand, improvements made in the field of lung surgery prompt some physicians and patients to pursue surgical treatment. We assessed the results of surgical treatment of bronchiectasis and compared them with the results of medical treatment during the same period of time. The study population consisted of all patients who had referred to Masih Daneshvari Hospital and were admitted for treatment of bronchiectasis during a period of seven and a half years [March 1999 to September 2006]. In this descriptive study, surgical or non-surgical treatment was adopted according to the usual indications for the treatment of bronchiectasis. Response to treatment was evaluated by referring to the patient's medical records and out-patient visits. The results were categorized into the following categories: Sputum production and other major signs completely disappeared. Satisfactory: Signs and symptoms did not totally disappear, but the patient was satisfied with the treatment results. Poor: No significant change was seen after the treatment. Technique of surgery was postero-lateral thoracotomy under one lung ventilation and lobar or segmental resections. Medical treatment consisted of physiotherapy, antibiotic administration and vaccination against influenza and pneumococcus. Statistical analysis was performed using Access and SPSS software. Fisher exact and chi square tests were used for qualitative comparison of the results. The mean duration of follow- up was 35.9 months [range 1-96 months]. Eighty-three patients were studied [48 females, 35 males, mean age 37.8 years, range: 8-71 years]; 40 patients underwent surgery while 43 underwent medical treatment. The results of surgery were good in 16[55.2%], satisfactory in 10 [34.5%] and poor in 2 [6.9%] patients. The results of medical treatment were good in 4 [13.8%], satisfactory in 11[37.9%], and poor in 13 [44.8%] patients. Good results were significantly more [P=0.002] and poor results were significantly less [P=0.002] after surgical treatment. In each group, one death occurred during the treatment course. Fourteen patients in the medical group and 11 patients in the surgical group were lost during the follow-up period. When indicated, surgical therapy offers advantages over medical therapy in the treatment of bronchiectasis

Pulmonary metastatectomy and survival rate of patients

Although presence of pulmonary metastasis is indicative of disease progression and its untreatable nature, in recent decades, numerous efforts have been made for treatment of these patients by surgical resection of metastatic lesions. The efficacy of this procedure has been variable in various reports and different diseases. This study aimed to evaluate the effect of metastatectomy in survival rate of patients with pulmonary metastases who underwent metastatectomy in Masih Daneshvari hospital. This was a retrospective study and we evaluated medical records of 99 patients suffering pulmonary metastasis who had been referred to our center during 1995-2007; out of which 48 patients who were qualified for metastatectomy underwent this operation. The required qualifications for surgery included: feasibility of resecting all metastatic lesions, tolerance of surgery by the patient, absence of metastatic lesions in organs other than the lungs, and control of primary disease. Information regarding the site of primary lesion and its pathology, time interval between the diagnosis of primary disease and metastasis, surgical morbidity and mortality, form of surgical procedure, type of incision, number of pulmonary metastases and survival rate of patients was collected. Patients were followed up via clinical visits. In case of insufficient clinical visits, we contacted the patient or his/her family and collected the rewired data. Obtained data were analyzed using SPSS software. To assess the patients' survival rate after the operation, Kaplan-Meier test was used. Sixty-seven pulmonary metastatectomies were conducted on 48 patients [31 males and 17 females] in the age range of 16-86 years [mean 40 yrs]. Twenty-five patients had unilateral and 23 had bilateral metastases. Among patients with bilateral metastases, 7 underwent single-phase metastatectomy while 16 underwent two or multi-phase metastatectomy. Surgical incisions were done through the following approaches: in 60 cases through postero-lateral thoracotomy, in 4 cases through mid-sternotomy and in 3 cases through bilateral anterior-transverse thoracotomy along with sternotomy [clamshell]. In 61 cases pulmonary metastatic lesion was removed by wedge resection, in 14 cases by lobectomy and in one case by pneumonectomy. Mean number of resected lesions was 6.7 [range 1 to 59]. Post-operative complications occurred in 10 patients [15%] including pneumothorax in 9 cases and chylothorax in one. No morbidity, mortality or life-threatening complications occurred in any of the patients. The mean survival of patients following metastatectomy was 22 months [range 1 to 128 months] and their 5-year survival was 24.5% Five patients had 5 years [60 months] or more survival. Although the under-study population was not homogenous pathologically, it seems that metastatectomy with acceptable morbidity, increases the survival of patients and in some cases results in their complete recovery

Surgical treatment of complicated pulmonary hydatid cyst

Hydatid disease is caused by an infection with the cestode, Echinococcus granulosus and is endmic in Iran. Medical therapy and surgical management are two main treatments. The purpose of this study is to represent our ten-year experience in surgical management of patients with complicated pulmonary hydatid disease including cysts ruptured into the pleural space or bronchi, multiplicity, hemoptysis, large size cysts and coexistence with liver cysts. Medical records of 109 patients, who underwent surgery for the treatment of pulmonary hydatid disease in Masih Daneshvari Hospital from December 1995 to October 2005, were reviewed. Among these patients, we selected our study group in accordance with the following criteria: 1] Cyst rupture into the pleural space or bronchi, 2] Occupying more than two third of the hemithorax in radiological studies, 3] Multiple cysts, 4] Massive hemoptysis, and 5] Synchronous pulmonary and liver cysts. Among the 109 patients with pulmonary hydatid cyst, 82 patients [59% male and 41% female] met the above mentioned criteria. The mean age of patients was 31.7 years [range 9-80 yrs]. The cyst diameter was determined by radiological imaging. The mean diameter was 6.23 cm, and 13 patients had giant cysts [occupying more than 2/3 width of the hemithorax]. In this study group 55 patients had ruptured hydatid cysts, 29 had multiple cysts, 11 had significant hemoptysis and 15 had synchronous pulmonary and liver cysts. All patients had undergone surgery with or without previous medical therapy. Our procedure of choice was thoracotomy, cystectomy and closure of the bronchial openings before irrigating the cavity with silver nitrate [0.5%] soaked sponge. Pulmonary resection was done in 8 patients due to the irreversible parenchymal damage. Post operative complications occurred in 16 [19%] patients including residual pleural space in 8, broncho-pleural fistula in 2, pleural effusion in 1, pulmonary embolism in 1, osteomyelitis of sternum in 1, laceration of diaphragm in 1, and inability to access the liver hydatid cyst after thoracotomy and post operative pulmonary insufficiency necessitating mechanical ventilation also in 1 patient. One patient died because of sepsis [she had been operated on for combined pulmonary and liver hydatid disease]. In the 1 to 60 months follow up period, 2 recurrences occurred. Although post operative complications occurred in 19% of our patients, all were treated by conservative managements. This rate of complications was acceptable among patients with complicated hydatid disease. Our procedure of choice is draining the cyst; closing all the bronchial openings in the pericyst and leaving the pericyst cavity open into the pleural space

unusual presentation of hodgkin's lymphoma as a chest wall abscess in association with old tuberculosis

Chest wall abscess is a very rare presentation of extranodal Hodgkin's lymphoma. Only a few case reports have been found in this regard. Here, we describe a chest wall mass developed in association with tuberculosis in an 82-year-old woman. Radiologic examination revealed two masses outside of chest wall that lead to destructive changes in the manubrium of sternum. The diagnosis of Hodgkin lymphoma was made by open surgical excisional biopsy of the chest wall mass. This is a very unusual extranodal presentation of Hodgkin's lymphoma

Effect of chest tube suction on air-leak following lung resection

Air-leak is of the common complications of pulmonary resection, yet there is no consensus on its management. Some authors are in the belief that if, after surgery the lung can remain open, absence of suction will quickly stop the air-leak from the chest tube, whereas others believe that using the suction is essential. This study aims to evaluate the role of chest tube suction after surgery. This is a randomized clinical trial performed on 31 patients who underwent different lung surgeries. After surgery, chest tubes of all patients was connected to the suction till the next morning. Afterwards suction was discontinued for 3 hours and chest radiography was obtained. In presence of pneumothorax in chest-x-ray or in cases of airleakage from the chest tube, use or no use of chest tube suction was determined randomly. In 13 out of 31 patients, chest tube suction was used. In these patients, adding the suction had no effect on shortening the duration of air-leak or hospital stay. We also tried to evaluate the probable effective causes of air-leak in these patients. In this regard we did not find any relation between the age, FEV1 and PaO2 before the operation with air- leakage after the surgery. But there was a significant correlation between the rate of air-leakage and PaCO2 before the surgery. Risk of air-leakage on the 7th day after surgery was greater in those patients in whom the degree of air-leakage was higher on the first day. Use of chest tube suction had no effect on controlling the air-leakage. In this study, use of chest tube suction had no effect on shortening the air- leak period after surgery. In our patients, PaCO2 was an important factor in predicting the risk of air-leak from the chest tube

Management of delayed diagnosed esophageal perforation

The esophageal perforation can be fatal unless diagnosed promptly and treated effectively. The high mortality rate related to delayed treatment is due to an inability to effectively close the perforation site to prevent leakage and ongoing sepsis. This study was performed on patients who were referred to three hospitals of Shaheed Beheshti and Tehran Universities of Medical Sciences during two years. All patients admitted in these hospitals with esophageal perforation lasting for more than 24 hours were studied. There were 24 patients [12 males, 12 females] with the mean age of 37.5 yrs. The most frequent symptoms and signs were: Chest and abdominal pain in 11 cases [45.83%], empyema in 11 cases [45.83%], fever in 10 cases [41.66%], pleural effusion in 8 cases [33.33%] and emphysema in 3 cases [12.5%]. The most common causes of esophageal perforation were use of devices during esophagoscopy and foreign bodies in 13 cases [54.17%], iatrogenic trauma in 4 cases [16.67%], Boerhaave's syndrome in 4 cases [16.67%], ingestion of burning chemicals in 2 cases [8.33%] and esophageal cancer in 1 case [4.17%].Four [16.66%] of all patients died while others were discharged with no significant complication in long time. This study was performed on patients referred to university hospitals; therefore, the results are different from those of community. Most of the perforations were due to intraoperative negligence or device manipulation. The outcomes of the whole procedures were good concluding that late diagnosed esophageal perforations can be managed surgically with good results but with a longer period of hospitalization

Suicide attempts as the cause of post intubation airway stenosis [PIAS]

The incidence of suicide attempt has been increasing in recent years. Presenting a group of patients who attempted suicide, underwent ventilatory support and developed postintubation airway stenosis [PIAS] may help us in prevention and better understanding of this complication. Among patients who referred to our center for treatment of PIAS, those who had been intubated for suicide attempt were investigated in a prospective study. Information was entered in a questionnaire and regular follow ups were done in a 15-month period [April 2003 to July 2004]. Among 100 patients with PIAS, 19 enrolled in this study including10 females and 9 males [mean [ +/- SD] age, 25.3 [ +/- 9.96] yrs; ranging from 17 to 56 yrs]. Type of disease and reasons of suicide were categorized by a psychologist as follows: Eleven patients with psychosocial stress along with an immature personality back-ground, 7cases of psychological disorders and one with an unknown cause. Direct causes of committing suicide included family problems in 10 cases, lovesick in 2, addiction in 3, depression in 6 and social problems in 2 cases [some patients mentioned two reasons and one refused to mention the reason]. Mean time of intubation was 14.78 days [3-30 days], and the mean length of stenosis was 35.12 mm [20-50 mm], 8 patients underwent tracheostomy. Three patients were treated with bronchoscopic dilation and 16 underwent laryngotracheal resection and reconstruction. There were 8 cases of recurrence after resection among which 4 were treated by second resection, 2 recovered by bronchoscopic dilation and 2 managed by stenting. This group of patients [study group] was compared with a similar group of patients in whom the causes of intubations were different [control group]. Incidence of postsurgical recurrence [p=0.011] and the length of stenosis [p=0.01] were higher in the study group. In our patients, social problems such as unemployment, illiteracy and singleness were the more frequent causes of suicide compared with psychological disorders. Patients who undergo mechanical ventilation due to suicide and develop PIAS could be treated by tracheal resection and reconstruction; although the incidence of post- surgical recurrence is higher in them compared with the other groups of patients with PIAS

Systemic primary amyloidosis presenting as generalized lymphadenopathy and massive pleural effusion

A 73 year-old man with cough, dyspnea, generalized lymphadenopathy and left sided pleural effusion was admitted with primary impression of lymphoproliferative disorders. The precise evaluation showed systemic primary amyloidosis with the rare presentation of generalized lymphadenopathy and massive pleural effusion without any other organ involvement as the available tests showed

Ligation of the major mediastinal vessels, safety and complications

Background: During upper mediastinal surgical interventions, innominate vessels may be ruptured inadvertently or divided intentionally by the surgeon for a better exposure. The question, whether a divided innominate artery or vein should be reconstructed or not, has not yet been clearly answered

Materials and Methods: In a retrospective study, 11 patients who underwent surgery between 1996 and 2004 in our department [7 females and 4 males] with mean age of 38.7 years old were found undergoing an upper mediastinal surgery with ligation of a great vessel. Fourteen great vessels [6 innominate arteries, 4 left innominate veins, 3 right innominate veins and one right carotid artery] were ligated with no reconstruction. The vessels were intentionally divided for a better exposure or ligated for controlling of severe bleeding [due to an iatrogenic trauma] in 6 and 5 patients, respectively

Results: One patient with innominate artery and right innominate vein division suffered from a 48 - hour period of coma due to a cerebral edema which was completely resolved. Two patients developed infection at the site of sternotomy and were managed with antibiotics and wound care. No complication occurred in the remaining. In two cases with division of innominate arteries, the peripheral pulses disappeared, but there was no muscle weakness, or ischemic pain in the limb. The follow-up period was between 2-96 months [mean; 24.8]

Conclusion: In critical condition and when surgical situation is not suitable for reconstruction, innominate vessels could be safely ligated and divided for a better surgical exposure and control of bleeding; with acceptable post-op risks