Diagnosis and repair of a Morgagni hernia with video-assisted thoracic surgery.

Foramen of Morgagni hernias have traditionally been repaired by either an abdominal or a transthoracic approach. We describe a case in which a Morgagni hernia that presented as a gradually enlarging right anterior pericardiophrenic mass was both diagnosed and repaired using video-assisted thoracic surgery. The procedure went without incident, and the patient had an uneventful postoperative course. The video-assisted thoracic surgical repair can be a safe and effective way to fix a Morgagni hernia.

Video-assisted talc pleurodesis in the management of pleural effusion secondary to continuous ambulatory peritoneal dialysis: a report of three cases.

Continuous ambulatory peritoneal dialysis (CAPD) is an effective treatment for end-stage renal disease. Hydrothorax secondary to pleuroperitoneal communication is an unusual complication of CAPD, with persistence or recurrence requiring alternate forms of dialysis. We have recently managed three patients with CAPD-induced right hydrothorax secondary to such communications. Earlier treatment methods have included thoracentesis or tube thoracostomy with chemical pleurodesis and even thoracotomy with attempts to locate and close the communication. We used a new approach consisting of video-assisted thoracic surgery and direct talc poudrage. All patients were successfully returned to CAPD; one patient required a repeat procedure after an initial recurrence. Video-assisted thoracic surgery with talc poudrage is an effective and safe procedure with minimal morbidity for management of hydrothorax secondary to CAPD. This procedure allows identification of diaphragmatic defects amenable to repair and talc placement under direct visualization, allowing even distribution over the inferior surface of the lung.

Video-assisted thoracic surgery: primary therapy for spontaneous pneumothorax?

BACKGROUND: This study assessed the role of video-assisted thoracic surgery (VATS) in current therapy for spontaneous pneumothorax. METHODS: We compared a retrospective series of 89 patients treated conventionally with a consecutive group of 30 patients undergoing VATS pleural abrasion. The 89 earlier patients were predominantly male (81%). Treatment groups included observation/aspiration (7 or 17%), tube thoracostomy (32 or 36%), multiple tubes (7 or 9%), and thoracotomy (43 or 48%). Of the 30 patients treated with VATS, 18 (66%) were male. Primary indications for operation were recurrent pneumothorax (17) and persistent air leak (9). RESULTS: Hospital lengths of stay (LOS) for the earlier group were 5 days for simple tube and 7 days for primary thoracotomy; LOS for initial intervention followed by thoractomy exceeded 15 days in all subgroups. The average LOS in the VATS group was 13 days; 6 patients treated with primary VATS (no chest tube) had a mean LOS of 6.5 days. Complications included 3 (10%) prolonged air leaks (more than 7 days) and 2 (7%) early recurrences. CONCLUSIONS: We do not recommend VATS as primary therapy for spontaneous pneumothorax; tube thoracostomy remains the treatment of choice. However, we strongly support surgical intervention early (3 days) in patients with a persistent air leak, and as primary therapy in a nonurgent situation if standard indications exist. This study shows no advantage of VATS over conventional thoracotomy in hospital stay or complication rate.

Cerebral imaging in the asymptomatic preoperative bronchogenic carcinoma patient: is it worthwhile?

The issue of screening for cerebral metastatic disease in the preoperative bronchogenic carcinoma patient remains unsettled and changes with advancing technology. A prospective nonrandomized study was designed to compare contrast magnetic resonance imaging (MRI) with computed tomography (CT) after several clinical situations suggested improved sensitivity for the former study. Patients with clinically operable disease and normal neurologic examinations were referred for both enhanced cerebral CT and MRI studies. Forty-two patients were entered and completed the enhanced CT scan; only 30 tolerated the MRI. The demographic data and histology of the patients appeared fairly typical for a series of operative candidates. No unsuspected metastatic lesion was found in this selected and low-risk group. We conclude that neither MRI nor enhanced CT scan is indicated in the asymptomatic bronchogenic carcinoma patient due to expense and lack of positive findings. Magnetic resonance imaging demonstrated more subtle benign pathology, but this study did not allow comparison of the two techniques in detection of metastatic disease.

Penetrating injuries of the aortic arch and its branches.

Acute cardiac failure, pulmonary edema, and ischemia of the brain, cord, and other structures pose special problems with trauma to the aortic arch and its branches. Data on 93 such cases are reported. Diagnosis was made by clinical examination in hemodynamically unstable patients and led to immediate operation in 61.3%. Patients in stable condition had angiography, which localized the injury and allowed planning of incision and bypass shunts. In left subclavian artery injuries, anterior thoracotomy was best for proximal control regardless of wound entry sites; midline sternotomy with sternocleidomastoid extension was usually adequate for other vessels. Flow was reestablished in all carotid injuries; there were no neurological complications. Temporary or permanent bypass shunts during periods of proximal aortic occlusion were valuable in decreasing cardiac afterload, maintaining circulation to the brain, and allowing an unhurried methodical approach to the hematoma. Occlusion of one or more venae cavae alleviated acute cardiac dilatation during brief periods of ascending aortic clamping. Associated trauma contributed to the high mortality.

Blastomycosis of the lung: CT features.

The authors reviewed the computed tomographic (CT) scans in 16 patients with pulmonary blastomycosis to describe the abnormalities seen at CT. The CT features were as follows: mass lesions (n = 14), consolidation (n = 9), air bronchograms (n = 14), intermediate-sized nodules (n = 12), satellite lesions (n = 11), pleural thickening (n = 4), small effusions (n = 2), and cavitation (n = 2). One patient had noncalcified hilar lymphadenopathy. Eight patients had acute disease, six had chronic disease, and two had acute exacerbation of a chronic illness. Fifteen patients had cough, fever, and/or dyspnea. Two patients underwent surgical resection for the presumptive diagnosis of bronchogenic carcinoma. In general, there was no correlation between the radiologic abnormalities and the clinical presentation. Consolidation occurred more frequently in acute disease. CT may be useful to help define the radiologic findings and distribution of disease. Familiarity with the characteristic CT findings of pulmonary blastomycosis may encourage an expeditious diagnostic approach to identify the disease and, possibly, prevent unnecessary surgical resection.

Mediastinal emphysema secondary to dental restoration.

Barotrauma due to oral procedures, although widely reported in dental publications, is rarely discussed in the medical literature. We report the case of a 42-year-old woman with mediastinal emphysema after a mandibular restoration and discuss management of this complication.

Delayed chest wall pain due to sternal wire sutures.

This report describes 18 patients with disabling chest wall pain due to one or more sternal wire sutures. The pain occurred from 2 to 84 months after a median sternotomy. The pain was described either as sharp and stabbing or as a deep-seated ache. The involved wires had an exaggerated fibrous tissue reaction surrounding the twisted portion. The adjacent noninvolved wires had minimal reaction. In the last 7 patients, serial sections of the fibrous tissue revealed entrapment of one or more sensory nerve fibers. In 6 of the 7 electrical potentials were measured and found to be elevated, indicating wire damage during twisting. Ferroxyl tests confirmed the collection of iron ions at this anodic point as a result of corrosion. Removal of the involved wires and the fibrous tissue surrounding this anodic point relieved the symptoms of pain and tenderness resulting from entrapped sensory nerves.

Invasive pulmonary penicilliosis: successful therapy with amphotericin B.

We have described a patient with invasive pulmonary penicilliosis, documented by thoracotomy and cured with amphotericin B. Penicillium sp isolates in immunosuppressed patients should not be disregarded without a thorough investigation, especially if normally sterile sites are involved. Amphotericin B therapy may be successful, especially if accompanied by a reversal or moderation of immunosuppression.

Benign fibrous pleural tumor with elevation of insulin-like growth factor and hypoglycemia.

We have reported the case of a 69-year-old woman with a hugh benign fibrous tumor of the left pleura and hypoglycemic seizures. Increased preoperative levels of insulin-like growth factor (IGF II) were present; insulin level was low and plasma levels of somatomedin C were normal. After resection of the 2,400 gm tumor, blood sugar level has remained normal, and IGF II has fallen to normal limits. This appears to be the first reported case documenting elevated serum IGF II in association with a benign fibrous pleural tumor.

Spontaneous rupture of the esophagus: a 30-year experience.

This retrospective review of 34 patients with spontaneous rupture of the esophagus, which spans a 30-year period, attempts to identify areas in diagnosis and therapy that might alter the dismal prognosis. The diagnosis and definitive surgical repair of Boerhaave's syndrome were frequently delayed. Delay resulted in a significant increase in complication rates. Pain (85%) and vomiting (71%) were the only common historical events suggesting the diagnosis. Physical examination was of aid in the diagnosis in only the 9 patients (27%) who demonstrated cervical or mediastinal emphysema. The initial chest roentgenogram was abnormal in 97% of the patients, but was interpreted as "compatible with perforation of the esophagus" in only 27%. Esophagography was diagnostic in 23 of 24 patients in whom it was used. Thoracentesis was of little diagnostic aid, but pleural fluid pH was measured in only 15% of the patients. Prompt surgical repair, regardless of time after onset, appears to be the indicated therapy.

Does open lung biopsy affect treatment in patients with diffuse pulmonary infiltrates?

The decision to perform open lung biopsy in the evaluation of a diffuse pulmonary infiltrate is based on the probability that this examination will yield specific information that may lead to a change in treatment. The role of this procedure remains controversial and many clinicians are reluctant to allow this invasive procedure without assurances that results will lead to a change in therapy for a significant number. To evaluate the impact of open lung biopsy on diagnosis and treatment of diffuse pulmonary infiltrates, we conducted a retrospective review of 61 patients undergoing this procedure at three university-affiliated hospitals during a recent 7-year period. There were 37 men and 24 women; average age was 57 years. Biopsy yielded a specific diagnosis in 21 (34%) patients and a change in therapy in 33 (54%) patients. A complication developed in 11 (18%) patients, directly related to the biopsy procedure in six (10%). Eight patients died. The immune status in 22 (36%) patients was compromised. A specific diagnosis was obtained in 13 (59%) immunocompromised patients and a change in therapy occurred in 17 (77%) of these patients after biopsy. A specific diagnosis was obtained in only eight (21%) of the 39 noncompromised patients and therapy was changed in 16 (41%) patients in this group (p less than 0.02 compromised versus noncompromised). Morbidity and mortality were not significantly different between the two groups. A nonspecific diagnosis led to a change in therapy as frequently as a specific diagnosis in both compromised and noncompromised groups. Open lung biopsy in the patient with a diffuse pulmonary infiltrate is an accurate diagnostic tool and frequently leads to a change in patient treatment. The procedure can be performed with acceptable morbidity and mortality in immunocompromised and noncompromised patients.

Management of broncholithiasis: is thoracotomy necessary?

Endoscopic treatment of broncholithiasis is controversial. From 1953 through 1984, 66 operations were performed on 40 patients with broncholithiasis in an endemic area for histoplasmosis. They are reviewed here retrospectively. All patients had cough; wheeze, hemoptysis, and lithoptysis were present in 60%, 45%, and 26%, respectively. Bronchoscopic stone removal was successful in 19%, whereas 21% of patients required no treatment. The 25 patients who were affected more severely required thoracotomy and operations varying from simple lung wedge resection to repair of a bronchoesophageal fistula. Optimum preservation of lung function was a major treatment guideline. All survived, and most have returned to normal preoperative activity. For selected patients, bronchoscopy and stone removal may be all that is required for broncholithiasis.

Transdiaphragmatic intercostal hernia.

A 72-year-old man was seen with cough-induced rib fractures, a diaphragmatic tear, and an intercostal hernia containing abdominal contents. A review of the literature of this rare problem is presented, and techniques of repair are discussed.

The British Telecom radiopaging service in general practice.

This paper reports a new radiopaging service supplied by British Telecom that will eventually cover the whole United Kingdom. The use of this service by a three-man practice is described. The service is considered to be a major development in communications that will be of interest to most general practitioners.