RESUMO
A Morgagni's hernia is a congenital defect found in the anterior aspect of the diaphragm between the costal and the sternal portions of this muscle. This defect is also referred to as the space of Larrey. It has been reported that 70% of patients with Morgagni's hernia are female, 90% of the hernias are right-sided, and 92% of the hernias have hernia sacs. This type of hernia is a rare clinical entity and accounts for 3% of all surgically treated diaphragmatic hernias. There are no large retrospective or prospective studies on this topic. This type of hernia is a rare type among adults without a well-described prevalence and without well-established definitive management strategies. There are also few clinical reports about this clinical entity and its surgical treatment. We treated 21 patients with Morgagni's hernia in a 12-year period, and we report our experience while discussing the surgical treatment of this disease. We performed a retrospective review of the 21 patients who were operated between 2003 and 2015. These patients had undergone surgical repair of Morgagni's hernia. For each subject, demographic data, symptoms of presentation, physical examination findings, preoperative imaging studies and diagnosis, and surgical procedures were documented. Location of the hernia sac and its contents, postoperative complications, and duration of hospital stay were recorded and evaluated. Twelve patients were females and nine were males. The mean age of patients was 63.85 years. Dyspnea was the most prominent symptom in our patients. Morgagni's hernias were located on the right side in 19 patients and on the left side in 2 patients. Chest X-ray in 10 patients and abdominal computerized tomography in 17 patients were the major diagnostic tools. Four patients were operated as emergency while others underwent elective surgery (17 patients). Twelve patients were operated with laparoscopy and the remaining nine were operated with the conventional open abdominal technique. Hernia sacs were observed in all of the patients and removed except in four of them. The omentum and the transverse colon were the most commonly seen organs in hernia sacs. Hernia defects were repaired with primary sutures in four patients (all open cases) and primary closure supported with mesh in six patients (four laparoscopic, two open cases). In the remaining 11 patients, hernia defects were closed with synthetic meshes (eight laparoscopic, three open cases). Mean postoperative hospital stay was 9.8 days. No recurrence was observed in any patients. Only one of our patients died during follow-up. In Morgagni's hernias, surgical intervention is necessary as the hernia may cause complications such as strangulation of the colon or intestines. A laparoscopic approach has increased its popularity in recent years because of the well-known advantages of laparoscopy.
RESUMO
BACKGROUND: Acute postthoracotomy pain is a well-known potential problem, with pulmonary complications, ineffective respiratory rehabilitation, and delayed mobilization in the initial postoperative period, and it is followed by chronic pain. The type of thoracotomy, intercostal nerve damage, muscle retraction, costal fractures, pleural irritation, and incision scar are the most responsible mechanisms. OBJECTIVE: Our aim was to assess whether preoperative ultrasound suprascapular nerve block with thoracic epidural analgesia was effective for postthoracotomy shoulder pain relief. METHODS: Thirty-six American Society of Anesthesiologist classification physical status I-III patients (2011-2012), with a diagnosis of lung cancer and scheduled for elective open-lung surgery, were prospectively included in the study. Eighteen of the patients received an ultrasound-guided suprascapular nerve block with 10-mL 0.5% levobupivacaine, using a 22-gauge spinal needle, 1 hour before operation (group S); 18 other patients had thoracic epidural analgesia only, and no nerve block was performed. Standard general anesthesia was administered. Degree of shoulder pain was assessed by a blinded observer when discharging patients from the recovery room, and thereafter at 1, 3, 6, 12, 24, 36, 48, and 72 hours on infusion at rest and 12, 24, 36, 48, and 72 hours on coughing. The same blinded observer also recorded the total amount of epidural levobupivacaine and fentanyl used by the 2 groups. RESULTS: In the suprascapular block group, the total amount of levobupivacaine (P = 0.0001) and fentanyl (P = 0.005) used postoperatively was statistically lower than in the epidural group. Visual analogue scale measurements in the suprascapular group were statistically significantly lower at 0, 1, 3, 6, 12, 24, 36, and 48 hours than those in the epidural group, both at rest and coughing. CONCLUSION: Postthoracotomy shoulder pain reduces patient function and postsurgical rehabilitation potential after thoracotomy, and various studies on explaining the etiology and management of postthoracotomy shoulder pain have been conducted. Theories of the etiology involved either musculoskeletal origin or referred pain. In this study, we concluded that preoperative ultrasound-guided suprascapular nerve block with thoracic epidural analgesia could achieve effective shoulder pain relief for 72 hours postoperatively, both at rest and coughing.
RESUMO
Metastatic diseases of thyroid are rarely seen. For the patients who had previous malignancy in their history, metastatic lesions should not be ignored in the differential diagnosis of massive lesions in the thyroid gland, even the primary tumor was treated years ago. In this article, we present a case with lung adenocarcinoma which was metastatic to the thyroid gland.