Transdiaphragmatic intercostal hernia following a penetrating thoracoabdominal injury: report of a case.

Intercostal hernias with abdominal viscera have rarely been reported following penetrating accidental or surgical trauma. We report herein a case of a traumatic rupture of the left hemidiaphragm, presenting as an intercostal hernia 2 years after a penetrating thoracoabdominal injury. The diaphragmatic rupture had been initially very small and could not be detected in the serial chest films and abdominal computed tomographic scans. The injury was also missed during an exploratory lateral thoracotomy. The patient was admitted with the chief complaint of a painful and gradually enlarging left-sided chest wall bulge of 8 months' duration. Surgery via an anterolateral thoracotomy along the axis of the intercostal hernia was performed, and the omentum and splenic flexura of the colon were reduced.

Descending necrotizing mediastinitis: a case report and review of the literature.

Descending necrotizing mediastinitis (DNM) is a highly fatal disease and as infection spreads along deep cervical planes into the mediastinum, widespread cellulitis, necrosis, abscess formation, and sepsis may occur. Early diagnosis is crucial for starting aggressive treatment without delay. Cervicothoracic computed tomography (CT) scanning may be useful for early diagnosis and preoperative evaluation of the surgical approach. Optimal treatment includes broad-spectrum antimicrobial therapy and extensive cervicomediastinal and transthoracic drainage. Clamshell incision provides an excellent exposure of both thoracic cavities and all mediastinal structures with minimal morbidity. We report here a fatal case of DNM with bilateral empyema and purulent pericarditis due to an odontogenic abscess with a brief review of the literature.

One-stage operation for treatment after delayed diagnosis of thoracic esophageal perforation.

Perforation of the thoracic esophagus can be fatal unless diagnosed promptly and treated effectively. The high mortality with delayed treatment is principally due to the inability of effectively closing the perforation and preventing the leakage. We operated one patient with a delayed diagnosis of thoracic esophageal perforation developed after a rigid esophagoscopic procedure. The perforation was closed with primary sutures and reinforced with a intercostal muscle flap wrap. Radical decortication and wide mediastinal and pleural toilet were also done. Total parenteral nutrition was begun and antibiotics were administered according to the results of cultures. Esophagography and esophagoscopy performed 10 days after the operation showed a well healed esophagus without stenosis or leakage. We conclude that primary closure of the perforation and muscle flap wrap can provide a one-stage operation with good results for repair of thoracic esophageal perforations which are not diagnosed on time.

Serum protein and zinc levels in patients with thoracic empyema.

The element Zn is the metal component or activator of many important enzymes. The tissue concentrations and activities of Zn metalloenzymes direct the rate of protein and nucleic acid syntheses, thereby influencing tissue growth and reperative processes. Most of the serum Zn is normally bound to circulating proteins. Low serum Zn concentrations might result from depletion of Zn-binding proteins. Serum protein and Zn concentrations have been reported to be depressed in patients with acute and chronic diseases. We compare the serum protein and Zn values of patients with thoracic empyema (n = 20) with those of a control group (n = 20). The values obtained in the empyema group were significantly lower than those in the control group before the study. Test group administered 220 mg zinc sulfate (ZnSO4.7H2O) over 20 d and there was a significant increase in the values for serum protein and Zn after the oral administration of the zinc sulfate.

Clinical experience with minitracheotomy.

In minitracheotomy, a relatively simple percutaneous technique for tracheal cannulation, a small-bore tube is inserted via the cricothyroid membrane to provide access to suction removal of excess secretion or aspirated material from the tracheobronchial tree. It allows efficient tracheobronchial toilet while preserving glottic function and avoiding the disadvantages of conventional tracheostomy and endotracheal intubation. The indications for minitracheotomy in 20 cases were excessive postoperative or postpneumonic secretion (14), difficulty with endotracheal suction (5) and acute airway obstruction (1). The only major complication was bleeding in one case. Minor bleeding occurred at the incision in two cases. The cannula was retained for 3-8 days and removal was followed by closure within 48 hours. There were no adverse laryngeal effects. Minitracheotomy was well tolerated by the patients and is a useful adjunct for removal of airway secretion and hospitalized patients.