The history of mediastinal teratoma.

The first discovery in 1823 of what has become known as mediastinal teratoma is discussed. The uniqueness of this tumor with its various spontaneous complications is described along with its early and often inept surgical therapies. This article highlights the development of the surgical treatment of mediastinal teratoma that has matured synchronously with the understanding of the physiology of the chest and the evolution of modern surgery.

Sequential herniation of stomach, then colon through the aortic hiatus.

A patient with a large paraesophageal hernia had a Nissen fundoplication via laparoscopy. He returned a year later with the transverse colon herniated into the chest. At operation, the hernia ostium was found to be the aortic hiatus. We believe that the original ostium was missed because of the limited exposure of the video-laparoscopic technique.

Spontaneous mediastinal hemorrhage: a case report with a review of the literature.

A patient on chronic hemodialysis presenting with shortness of breath and dysphagia was found to have massive hemomediastinum. A review of the world's literature prompted by this case reveals that this rare entity can be classified into three general groups: (1) hemomediastinum secondary to underlying bleeding disorder, (2) hemomediastinum secondary to hemorrhage into a mediastinal organ or gland, without underlying bleeding disorder and (3) idiopathic hemomediastinum, without underlying bleeding disorder. Therapy depends upon the underlying etiology and the severity of symptoms.

Why should thoracic surgeons understand basic biology?

Thoracic surgery is undergoing major changes. In addition to the well publicized political and economic upheavals, our patients and the diseases targeted are rapidly evolving. Much of the change is driven by an explosion of new biology that many in the field have little or no familiarity with. As molecular biology, immunology, and information about cytokines pervade our literature and practices, it is imperative that thoracic surgeons develop a basic understanding of these and other unique concepts. The best link between our clinical practice and the new biology is thoracic surgical scientists who are exposed to current information.

Pneumonectomy after contralateral lobectomy: is it reasonable?

Conservative resection of a second primary lung cancer is desirable but not always feasible. We recently carried out three left pneumonectomies for the removal of metachronous primary lung cancers in patients who had previously undergone right upper lobe resection for the treatment of bronchogenic carcinoma. In each patient, the results of pulmonary function tests plus the findings from quantitative perfusion lung scans predicted a postpneumonectomy forced expiratory volume in 1 second of at least 1.00 L. All 3 patients had uncomplicated postoperative courses, and were doing satisfactorily at follow-up 2 to 6 months later. One patient died 5 months after pneumonectomy due to unrelated causes, another died 8 months after pneumonectomy from infection after resection of a brain metastasis, and the third is doing well 15 months after pneumonectomy. The rarity of previously reported cases suggests that performing a pneumonectomy after contralateral lobectomy may be considered too radical. Our experience indicates the procedure may be considered if the patient's pulmonary function meets the standard criteria for pneumonectomy.

Effect of lung contusion on pulmonary hemodynamics.

Our purpose was to examine changes in pulmonary hemodynamics for patients with pulmonary contusion. Pulmonary vascular resistance index (PVRI) and shunt fraction were calculated from standard measurements in 25 traumatized patients. The percent of lung volume injured, measured as air-space filling disease (ASF), was quantitated from computed tomograms using a previously described technique. The amount of reactive pulmonary vasoconstriction per unit of injury (PVRI/ASF) identified 3 groups of patients: 5 were reactors (PVRI/ASF greater than 15), 10 were weak-reactors (PVRI/ASF = 5 to 15), and 10 were nonreactors (PVRI/ASF less than 5). In the reactor group PVRI increased as the size of contusion (ASF) increased (r = 0.99). In weak-reactors PVRI also increased with the size of contusion (r = 0.93), but the slope was less pronounced. In both groups shunt fraction did not rise above 0.31. In the nonreactors, PVRI remained normal while shunt fraction increased with the extent of injury (r = 0.95). These results indicate that pulmonary vasoconstriction often occurs after pulmonary contusion. The vasoconstriction most probably represents a compensatory mechanism to limit perfusion of traumatized parenchyma, thereby minimizing increases in shunt fraction. Some patients (nonreactors) not demonstrating this response have unchecked increases in shunt fraction. This insight into the hemodynamic sequelae of pulmonary contusions may enhance our ability to provide optimal care for patients suffering from this injury.

Mid-descending aortic traumatic aneurysms.

Two patients with traumatic rupture of the mid-descending aorta successfully repaired are presented. Most clinical series of aortic tears do not include this entity. A review of the world literature reveals only 9 previous cases. In 6 of the 11 patients the diagnosis was either missed or delayed. In 4 patients the diagnosis was delayed or missed because of the absence of a superior mediastinal hematoma, and in 2 patients the diagnosis was delayed because of inadequate (single-plane) aortography. Suspicion may be lacking because of absence of the upper mediastinal hematoma considered to be the sine qua non for the diagnosis of aortic rupture. Although deceleration is considered to be the mechanism of injury in tears at the isthmus, severe hyperextension (often associated with fracture dislocation of the underlying thoracic vertebra) is considered to be the causative factor in descending aortic tears. Experience with the 2 patients presented here demonstrates that a high index of suspicion and complete two-plane aortography is required to avoid the potential for catastrophic outcome subsequent to overlooking a tear of the mid-descending aorta.

Pneumothorax: an unusual manifestation of a bronchial carcinoid.

Long-term successes in treating carcinoid tumors suggest that in poor-risk patients endobronchial resection, when possible, be considered the treatment of choice.

Highlights of the history of nonpenetrating chest trauma.

The basic principles of the pathology, physiology, diagnosis, and management of nonpenetrating chest trauma evolved to a significant degree before World War II. The advances in the past 40 years include more frequent use of endotracheal intubation, improved ventilatory assistance, better control of blood volume, antibiotics, the clinical application of blood-gas studies, diagnostic imaging, and specialized nursing and monitoring in intensive care units. Thus, the improvement in survival is not primarily attributable to operative measures but rather to enhanced supportive measures.