The role of video-assisted thoracoscopic surgery in the treatment of parapneumonic empyema after the failure of fibrinolytics.

BACKGROUND: Approximately 10% of patients treated with intrapleural instillation of fibrinolytics fail to respond and therefore need more invasive techniques, such as video-assisted thoracoscopic surgery (VATS). METHODS: During the period 1994-99, we treated 20 consecutive patients with complicated parapneumonic effusion (CPE) and pleural empyema (PE) that did not resolve with urokinase instillation given through the chest tube in a dose of 100,000 IU diluted in 100 ml of normal saline/daily for 3-5 days. The patients' ages ranged from 21 to 68 years (median, 46); 14 were male and six female. All patients had pleural fluid pH <7.1, LACTATE DEHYDRAGENASE (LDH) >1000, glucose <40 mg/dl and were submitted to VATS. RESULTS: Complete drainage was observed in 17 patients (85%), in the other three (15%), the procedure had to be converted to open thoracotomy due to a thickened visceral pleural peel. The mean operative time was 80.3 min (range, 55-140), and the mean duration of postoperative hospital stay was 7.5 days (range, 4-19). CONCLUSION: We found that VATS is a safe, effective, and well-tolerated surgical procedure in CPE and PE patients who have failed to resolve with initial treatment with fibrinolytics.

Management of simple thoracic injuries at a level I trauma centre: can primary health care system take over?

BACKGROUND: Overtriage is a problem for all trauma systems, including the Greek emergency system. In this study we examined the performance of the primary care emergency system in the treatment of patients with simple thoracic injuries, in the area of a Level I hospital. Our aim was to form organizational proposals and treatment and referral guidelines in an effort to improve the system's performance. METHODS: We reviewed the notes of 488 patients with a thoracic injury as their main complaint, seen and immediately discharged from the A+E department of a Level I hospital. RESULTS: Falls and road traffic accidents were the most common mechanisms of injury. The majority of the injuries were rib fractures or rib cage contusions. Many patients sought medical advice several days after the injury. Fifteen patients required conservative treatment for orthopaedic injuries. Clinical examination, X-rays and abdominal ultrasound were the most useful tests. CONCLUSIONS: Detailed clinical examination, time from injury and a chest X-ray usually identifies the patients who can safely be treated in primary health care facilities. Simple radiology services (X-ray and US) and training of general practitioners in basic emergency care principals in primary care health centres would reduce the number of referred patients with simple thoracic injuries.

Intrapleural urokinase versus normal saline in the treatment of complicated parapneumonic effusions and empyema. A randomized, double-blind study.

Intrapleural administration of fibrinolytic agents has been shown to be effective and safe in the treatment of loculated parapneumonic pleural effusions. However, controlled studies of the possible role of the activity of urokinase (UK) through the volume effect are lacking. We therefore investigated the hypothesis that UK is effective through the lysis of pleural adhesions and not through the volume effect. Thirty-one consecutive patients with multiloculated pleural effusions were randomly assigned to receive either intrapleural UK (15 patients) or normal saline (NS) (16 patients) for 3 d, in a double-blind manner. All patients had inadequate drainage through a chest tube (< 70 ml/24 h). UK was given daily through the chest tube in a dose of 100.000 IU diluted in 100 ml of NS. Controls were given the same volume of NS intrapleurally. Response was assessed by clinical outcome, fluid drainage, chest radiography, pleural ultrasonography (US) and/or computed tomography (CT). Clinical and radiographic improvement was noted in all but two patients in the UK group but in only four in the control group. The net mean volume drained during the 3-d treatment period was significantly greater in the UK group (970 +/- 75 ml versus 280 +/- 55 ml, p < 0.001). Pleural fluid drainage was complete in 13 (86.5%) patients in the UK group (two patients were treated through video-assisted thoracoscopy) but in only four (25%) in the control group. Twelve patients in the control group were subsequently treated with UK and six of them had complete drainage; the remaining six patients had complete drainage after video-assisted thoracoscopy. Our results suggest that UK is effective in the treatment of loculated pleural effusions through the lysis of pleural adhesions and not through the volume effect.

Artificial paravertebral widening for percutaneous CT-guided adrenal biopsy.

A percutaneous adrenal biopsy under CT guidance is described. The biopsy was performed after injection of physiologic saline solution into the paravertebral space, creating a wider pathway for needle insertion. This technique has been previously reported for biopsy of thoracic lesions, but in our case it was used for biopsy of a relatively inaccessible adrenal lesion. This artificial window that is formed by displacing the pleura laterally allows a direct and potentially safer access route to the retroperitoneum, avoiding puncture of pleura, diaphragm, and abdominal structures.

Intrapleural urokinase in the treatment of complicated parapneumonic pleural effusions and empyema.

Intrapleural urokinase has not been evaluated systemically in terms of efficacy, safety, and cost of treatment in a large series of patients with complicated (parapneumonic) pleural effusions (CPE) and pleural empyemas (PE). Furthermore, the optimal dose and duration of treatment is not known. Twenty consecutive patients with multiloculated parapneumonic effusions (13 with CPE and 7 with PE), in whom a single chest tube failed to drain the fluid, were studied prospectively. The age of the patients ranged 15-92 yrs (median 51 yrs). Urokinase was administered intrapleurally, in a low single daily dose of 50,000 U in 100 mL normal saline via the chest tube. Previous intrapleural instillation of 100 mL normal saline failed to promote drainage in all patients. Urokinase enhanced drainage in all patients. Clinical and radiological improvement was noted in all but one patient. The mean (SD) volume of fluid significantly increased in the first 24 h post-urokinase (p<0.001). The number of urokinase instillations ranged 3-7 (median 5). Radiological evaluation showed excellent improvement in 13 of the 20 (65%) patients. Urokinase was well-tolerated in all patients. The clinical course of patients was uneventful at a mean follow-up of 15 months (range 6-30 months) later. Mean total cost of treatment was $530 +/- 34.6. Our results show that intrapleural instillation of small doses of urokinase is a cost-effective and safe mode of treatment of complicated pleural effusions and pleural empyema and could be the fibrinolytic of choice.

Limb arterial injuries associated with limb fractures: clinical presentation, assessment and management.

OBJECTIVES: Review of limb arterial injuries associated with limb fractures. DESIGN: Retrospective study. SETTING: University Hospital. MATERIALS AND METHODS: The clinical presentation, assessment and management of 25 patients with upper (seven) and lower (18) limb arterial injuries associated with limb bone fractures has been retrospectively reviewed. MAIN RESULTS: Five patients presented with life threatening injuries and classic signs of acute limb ischaemia, 15 patients had an obvious limb arterial injury, and 5 presented with a suspected limb arterial injury. The site of arterial damage was: superficial femoral (4); popliteal (11); tibioperoneal trunk (3); anterior tibial (4); posterior tibial (3); peroneal (2); axillary (1); brachial (5); radial (4); and ulnar artery (4). The types of arterial repair were: autogenous vein interposition or bypass grafting (17); P.T.F.E. (2); end-to-end anastomosis (14); and ligation (8). The popliteal vein was injured in six cases, repaired in four and ligated in two; the superficial femoral vein was injured in four cases, repaired in three and ligated in one; and the axillary vein was injured in one case and was ligated. Primary nerve repair was employed in six out of seven injured nerves. Skeletal fixation preceded vascular repair in 21 patients and in four a Javid shunt was used. Intraoperative fasciotomy was performed in 12 out of 18 patients with lower limb ischaemia. Completion arteriography revealed residual thrombi in the distal foot of four patients, in whom intraarterial thrombolysis was effective. During the follow-up period of 1.5 to 2 years, the upper and lower limb preservation rate was 100 and 89%, respectively. The upper limb function was judged excellent in five patients, good in one and fair in one. In the lower limbs it was excellent in 11 patients, good in three, fair in one and poor in one. CONCLUSIONS: To ensure life and functional limb salvage of patients with devastating vascular injuries, a well organised multidisciplinary approach is necessary.

Role of streptokinase in the treatment of acute loculated parapneumonic pleural effusions and empyema.

BACKGROUND: Intrapleural administration of streptokinase has been shown in a few small series to be effective treatment for complicated parapneumonic effusions and pleural empyemas, but techniques of instillation of streptokinase differ. The role of streptokinase in promoting drainage was investigated prospectively in a larger series of patients with complicated parapneumonic effusions and pleural empyemas. METHODS: Twenty consecutive patients with parapneumonic effusions, 15 with complicated parapneumonic effusions and five with pleural empyemas, drawn from 160 patients presenting with pleural effusions were studied. The age of the patients ranged from 15 to 92 years. Initial thoracocentesis showed mean (SD) values of pH 7.1 (0.15), glucose 45.9 (17.5) mg/dl, white blood cell count 12,000 (6627)/mm3. Streptokinase was administered intrapleurally in a single daily dose of 250,000 units in 100 ml normal saline via the chest tube once the drainage was < 100 ml/24 hours. Patients were treated for 3-10 (mean 6) days. RESULTS: Following administration of streptokinase a clinical and radiological improvement was noted in all but one patient who died on the fourth day of hospitalisation due to widespread adenocarcinoma. Another patient with clinical but minimal radiological improvement underwent thoracotomy, but a clear pleural space with only fibrotic changes was found. The mean (SD) volume of fluid drained 24 hours before streptokinase was 42.5 (39) ml, which increased in the first 24 hours after streptokinase to 334 (130) ml. Radiological evaluation showed an excellent improvement in 14 of the 20 patients, a moderate improvement in three, and minimal improvement in the remaining three patients. One patient developed a high fever as an adverse reaction to streptokinase. All 19 patients who completed the treatment were well at follow up 6-30 months (mean 15 months) later. CONCLUSIONS: Intrapleural instillation of streptokinase is an effective and safe mode of treatment for complicated parapneumonic effusions and pleural empyemas and alleviates the need for thoracotomy.

Use of an ex situ, non-reversed great saphenous vein bypass graft for lower-limb ischaemia.

Use of an ex situ, non-reversed, great saphenous vein as an arterial bypass graft for arterial ischaemia of the lower limb is described. After exposing the inflow and outflow arteries of the ischaemic limb, the great saphenous vein of the contralateral healthy limb is prepared. The proximal end of the vein is anastomosed with the inflow artery of the ischaemic limb after incising the valves of the proximal vein. The distal part of the vein is then divided, the remaining valves retrogradely transected and, after ensuring that all vein valves have been rendered incompetent, the distal end of the vein is anastomosed with the outflow artery of the ischaemic limb.