Herniation of the lung after video-assisted thoracic surgery.

We report a case of lung herniation occurring following video-assisted thoracic surgery. Although lung hernias are rare, the widespread application of video-assisted thoracic surgery to patients at risk for lung hernia will likely result in more reports in the future. Consequently, pulmonologists and thoracic surgeons must be aware of this condition, risk factors for development, and potential methods of prevention in order to minimize the occurrence of this complication.

The lingula is an appropriate site for lung biopsy.

BACKGROUND: Lung biopsy is commonly performed for diagnosis of diffuse pulmonary disease. The lingula offers technical advantages for biopsy, however the quality of tissue obtained by lingula biopsy has been questioned. We sought to determine whether lingula biopsy was a satisfactory site for biopsy in terms of diagnostic yield, therapeutic interventions, and survival results. METHODS: All diagnostic lung biopsies performed for diffuse lung disease at 3 university affiliated hospitals between July 1, 1992 and December 31, 1998 were retrospectively reviewed. Patients were divided into 2 groups, depending upon site of biopsy: patients with lingula biopsy only and those with biopsies from other sites. RESULTS: There were 75 patients; 20 underwent biopsy of the lingula alone, 48 had biopsy of other sites with or without biopsy of the lingula, and location of biopsy was unknown in 7 patients. Histologic diagnosis was achieved in all patients. Significant beneficial therapeutic changes were made in 14 lingula patients, and consisted of immunosuppression in 12 cases. Three patients died in the hospital or within 30 days. Fourteen patients survived 1 year. There was no significant difference between patients that had biopsy of the lingula alone and those that had biopsies from other sites in urgency, technique, histologic diagnosis, rate of therapeutic interventions, hospital mortality, or 1 year survival. CONCLUSIONS: Lung biopsy of the lingula compared to other anatomic sites has equivalent diagnostic yield, therapeutic significance, and survival. Given the technical ease of biopsy, when disease is present radiographically it is the preferred site for lung biopsy.

Competitive NMDA receptor antagonists and spinal-cord ischemia.

Ischemic neuronal death is associated with excitatory amino acid (EAA) release. Their action is mediated by N-methyl-D-aspartate (NMDA) receptors. Blockade of the receptors before the ischemic insult can decrease neuronal damage. Accordingly, we investigated the protective effect during spinal cord ischemia of two competitive antagonists, 4-(3-phosphonopropyl)-2-piperazine-carboxylic acid (CPP) and cis-4-(phosphonomethyl)-2-piperidine-carboxylic acid (CGS). Male Sprague-Dawley rats underwent intrathecal administration of 10 microL saline, CGS, and CPP 10 mM solutions, in a randomized blinded fashion, and were subjected to balloon occlusion of the thoracic aorta. Proximal aortic pressure was lowered to a mean of 40 mm Hg by partial exsanguination. In the acute protocol, 21 rats divided in 3 groups of 7 (saline, CPP, and CGS) were used to calculate the aortic occlusion time (AOT) resulting in paraplegia in 50% of animals (P50). In the chronic study, 24 rats divided in 4 groups of 6 (saline, CPP, CGS, sham) underwent 12-min occlusion. The chronic animals were scored daily for 28 days and submitted to histology of the cord. In the acute study, the P50 of CGS (10 min 48 s) and CPP (11 min 11 s) was longer than saline (10 min 27 s). In the chronic groups, analysis of variance of neurologic (p = .66) and histologic (p = .66) scores did not disclose differences between CGS, CPP, and saline. In conclusion, blockade of NMDA receptors with CPP or CGS may afford some protection for durations of occlusion around the P50, but it is not beneficial when ischemic injury is more protracted.

Heterotopic pancreas of the esophagus masquerading as Boerhaave's syndrome.

Heterotopic pancreas (HP) of the esophagus is rare. We report a patient with HP of the esophagus and review the presentation, treatment, and results of the nine previously reported cases. Two patients had cancer. This high incidence raises concerns that HP of the esophagus may be premalignant. Because surveillance endoscopy is not possible, all known or suspected esophageal HP should be treated surgically.

Rodeo related large animal injury: is protective head-gear warranted?

To compare rodeo associated large animal injuries to large animal associated trauma from other aetiologies in order to determine whether mandatory protective head-gear during rodeo is warranted. Retrospective analysis related to injury involving large animal admissions between 1 January 1990 and 31 December 1995. The setting is at the University of New Mexico Health Science Center, a level 1 trauma centre. All patients admitted with Injury Severity Scores of 1 or higher following large animal associated injuries. There were 140 admissions for which mechanism of injury was known. Thirty-nine occurred during rodeo competition and 101 occurred during other activities. Bovine associated activities were the aetiology in 34 (87%) of rodeo related injuries while equine related activities were the aetiology in 97 (96%) of non-rodeo related injuries (P<0.001). Rodeo related injuries involved the head and neck in five patients (13%) compared to 42 patients (42%) in non-rodeo activities (P=0.001). Mean Regional Injury Severity Score head and neck was 0.4 for injured rodeo riders and 1.5 for injured non-rodeo riders (P<0.001). Mean admission Glascow Coma Scale was 14.9 for rodeo-injured patients and 13.3 for non-rodeo-injured patients (P<0.001). Total ISS was significantly lower for rodeo injured patients (9.1 vs. 11.7, P=0.03). No rodeo injured patient died as a result of head injury. Mechanism of injury, ISS head, GCS, total ISS, and outcome differ between rodeo and non-rodeo injuries. While routine helmet use during non-rodeo events appears justified, mandatory use of helmets in rodeo events is unwarranted. Orthotics to protect the chest and abdomen are more likely to reduce morbidity and mortality for rodeo participants.

Lung biopsy: is it necessary?

OBJECTIVE: Lung biopsy is associated with substantial mortality rates. We reviewed our experience with this operation, primarily in patients with immunocompetence, to determine whether the results justify the continued performance of this procedure. METHODS: We conducted a retrospective review of all diagnostic lung biopsies performed at 3 university-affiliated hospitals between July 1, 1992, and December 31, 1998. RESULTS: There were 75 patients: 25 patients were treated electively, 17 were treated on an urgent basis, 27 patients on an emergency basis, and the urgency was unclear in 6 patients. Significant beneficial therapeutic changes were made in 15 of 25 elective procedures (60%), in 16 of 17 urgent procedures (94%), and in 11 of 27 emergency procedures (41%; P =.001). Significant beneficial therapeutic changes consisted of immunosuppression in 13 of 15 (87%) patients treated on an elective basis, in 9 of 16 (56%) treated on an urgent basis, and in 9 of 11 (82%) treated on an emergency basis in whom therapy was altered (P =.14). Operative death was 0 of 25 for elective operations (0%), 3 of 17 for urgent operations (18%), and 14 of 26 for emergency operations (54%). Multivariable analysis of operative death showed urgency to be the only significant predictor of death (P =.002). CONCLUSIONS: In patients with immunocompetence, elective and urgent lung biopsies have acceptable operative mortality rates and frequently result in important beneficial therapeutic changes. Consequently biopsies are appropriate in these patients. Emergency biopsies are associated with high operative mortality rates and rarely result in a therapeutic change other than immunosuppression. These patients should not undergo lung biopsy if they are in stable condition and should be treated empirically with immunosuppression without operation if their condition is deteriorating.

Retrograde perfusion of the spinal cord during aortic crossclamping: initial observations in the swine model.

BACKGROUND: Retrograde perfusion has emerged as a useful technique for the preservation of the heart and brain when arterial circulation is interrupted. Herein, this study was designed to test the hypothesis that retrograde perfusion of the azygos vein is sufficient to maintain viability of the spinal cord during aortic occlusion in the swine model. METHODS: Female swine, 17 to 22 kg, underwent left thoracotomy, creation of a shunt between the aortic arch and the azygos vein, and aortic crossclamping for 60 minutes: the shunt was open in the retrograde perfusion group (n = 5) and closed in the control group (n = 4). The animals were evaluated for neurologic function for 8 days and killed. Spinal cords were processed for histologic examination. Additional animals underwent left thoracotomy and injection of a casting solution in the azygos vein (n = 2), left thoracotomy and angiography of the azygos vein (n = 2), and a compartmentalization procedure to separate the azygos vein from the caval system followed by angiography (n = 2). RESULTS: Differences in the neurologic (2-sample t test, P =.11) and histologic (2-sample t test, P =.65) scores of retrograde perfusion and control groups were likely due to chance. Casting and angiography groups showed extensive collaterals between azygos and caval systems, only partially interrupted by compartmentalization. CONCLUSIONS: Retrograde perfusion does not protect the spinal cord from ischemic injury. The collateral network between the azygos and caval systems prevents the oxygenated blood from reaching the cord. Surgical separation between the 2 systems was only partially successful in this study.

Selective protection of gray and white matter during spinal cord ischemic injury.

BACKGROUND: Ischemic injury in the gray matter is associated with excitatory amino acid neurotransmitters (EAA) release, and in the white matter is associated with intracellular sodium accumulation. We investigated the protective effect during spinal ischemia of the EAA antagonist, 2-carboxypiperazinyl-propylphosphonic acid (CPP), and the sodium channel blocker (2,6-dimethylphenylcarbamoylmethyl) triethylammonium bromide (QX). METHODS: Sprague-Dawley rats were randomized in four groups, received intrathecally 10 microL of saline, CPP, QX, or QX/CPP, and underwent balloon occlusion of the aorta. Proximal pressure was lowered by exsanguination. In the acute protocol, 28 rats were used to calculate the length of occlusion, resulting in paraplegia in 50% of animals (P50). In the chronic study, 60 rats underwent 11' occlusion. The chronic animals were scored daily for 28 days and submitted to cord histology. RESULTS: The P50 of QX (11'22") and QX/CPP (11'54") were longer than saline (10'39"), suggesting a beneficial effect. Neurologic scores of all treatment groups (p = 0.0001) and histologic scores of CPP (p = 0.003) and QX/CPP (p = 0.002) were better than saline. CONCLUSIONS: Protection of spinal cord during ischemia can be achieved with intrathecal administration of selective agents directed to the gray and white matter.

Cyanotic congenital heart disease with decreased pulmonary blood flow in children.

Of the "five T's" of cyanotic congenital heart disease--tetralogy of Fallot, TGA, TAPVC, truncus, and tricuspid valve abnormalities (tricuspid atresia, stenosis, and displacement)--the first and last are commonly associated with diminished PBF. The four features that comprise tetralogy of Fallot--right ventricular hypertrophy, VSD, overriding aorta, and subpulmonary stenosis--are all secondary to a single morphogenetic defect: failure of expansion of the subpulmonary conus. This also explains the variability in clinical presentation. When neonates need intervention, shunts are usually performed. Coronary arterial anatomy must be defined before repair, which is usually done after these infants are 3 months of age. Although children with repaired tetralogy of Fallot are not completely "normal," markedly increased longevity and improvement in quality of life can be achieved. When major associated defects are present, such as atrioventricular canal defect, diminutive pulmonary arteries or collateral vessels, or left heart lesions, the prognosis changes from excellent to merely good. Tetralogy of Fallot with absent pulmonary valve syndrome is physiologically different from other tetralogy of Fallot conditions and characterized primarily by airway obstruction from massive dilatation of the central and perihilar pulmonary arteries; repair with pulmonary artery reduction is necessary. Tricuspid valve abnormalities include atresia, hypoplasia (i.e., pulmonary atresia with intact ventricular septum), and displacement (i.e., Ebstein anomaly). The pathophysiology that dictates these children's clinical condition (and prognosis) relates to three factors: (1) status of the tricuspid valve, (2) presence and size of a VSD, and (3) TGA or normally related great arteries. Virtually all children with tricuspid valve abnormalities can be palliated; reparative options include repair using two-ventricle, one-ventricle, or 1-1/2 ventricle repair. Children with critical pulmonary stenosis generally have a normal tricuspid valve and right ventricle. Balloon dilation is usually the only therapy necessary.

Catastrophic hemorrhage on sternal reentry: still a dreaded complication?

BACKGROUND: To define the incidence of catastrophic hemorrhage (CH) during reoperations, the experience of the University of New Mexico was reviewed and compared with the practice of surgeons contacted by questionnaire. METHODS: At the University of New Mexico, 610 reoperations were reviewed and 210 deemed high risk because of multiple reoperation, aneurysm, patent grafts, chamber's enlargement, conduit or previous mediastinitis. In the questionnaire, we asked about reentry technique, occurrence and outcome of CH, and precautions for high-risk patients. RESULTS: At the University of New Mexico there were 4 CH with 1 death, and in the questionnaire there were 2,046 CH with 392 deaths. Our rate per surgeon was lower than that of the questionnaire. Rate of CH according to the saw was 2.09 for reciprocating, 2.0 for sagittal, and 1.74 for stryker in the questionnaire. Our rate was lower (0.65) with a micro sagittal saw. High-risk category predicted CH during sternotomy (p = 0.01) but only conduit (p = 0.005) was significant by univariate analysis. CONCLUSIONS: The risk of CH could be as high as 1%. The sagittal micro oscillating saw is the safest reported to date. Presence of a conduit increases the risk by 2.5 fold.

Transhiatal esophagectomy in a patient with aberrant right subclavian artery.

During transhiatal esophagectomy, the esophagus is generally safely and easily dissected posteriorly. However, in 1% to 2% of patients, an aberrant right subclavian artery passes between the esophagus and spine. We demonstrate that transhiatal esophagectomy may be safely performed in these patients when recognition and careful dissection are performed. Thoracic surgeons must be aware of this anomaly in order to prevent laceration of the aberrant right subclavian artery with catastrophic hemorrhage.

Choosing a prosthetic heart valve.

Although most of the available prosthetic heart valves function remarkably well, the variety of available choices attests to the inability of any single one to fulfill the requirements of the ideal valve substitute. The mechanical prostheses include the caged-ball, tilting-disc, and bileaflet valves. Tissue valves available in the United States are the Carpentier-Edwards and Hancock porcine heterograft valves and the Carpentier-Edwards pericardial valve. Review of several large comparative studies on valve performance reveals that the overall results with tissue and mechanical valves are about equal at the end of 10 years. The characteristics of each type of valve substitute dictate the selection of one prosthesis in preference to others for a particular patient. Mechanical prostheses are recommended for patients without contraindications for anticoagulants. Tissue valves are reserved for patients over 65 years of age or for patients in whom anticoagulation is contraindicated. Multiple other patient-related factors need to be considered in selecting the appropriate valve, including the psychosocial situation and patient preference.

Mediastinitis without antecedent surgery.

The study evaluates the results of aggressive surgical treatment for mediastinitis without antecedent surgery, after retrospectively reviewing all patients with mediastinitis, excluding patients with prior cardiac, esophageal or mediastinal operations, treated between June 1, 1992 and August 1, 1996. 8 patients were treated. 7 were male, mean age was 58 years. The etiology was Boerhaave's syndrome in 4, iatrogenic injury in 2 and descending necrotizing mediastinitis in 2 patients. The mean number of operations was 2.5. The initial operation was through thoracotomy in 5 patients and sternotomy in 2 patients. 4 patients underwent neck drainage, 1 as primary treatment and 3 combined with transthoracic drainage. 1 patient received laparotomy. Mean hospitalization was 52 days (excluding 1 death). Complications included mechanical ventilation greater than 48 hours in 7 patients, 2 or more operations in 5 patients, multisystem organ failure in 5 patients and other complications in 6 patients. Death occurred in one patients. Mediastinitis without antecedent surgery is associated with significant morbidity, however, with aggressive surgical drainage 87% of patients survived.

Sequestration of the lung arising from the circumflex coronary artery.

Sequestration is an unusual pulmonary malformation. Systemic blood supply is commonly from the thoracic aorta, but arteries may occasionally arise from other sites including the abdominal aorta or the intercostal vessels. We report a rare form of sequestration with origin from the circumflex coronary artery. Knowledge of uncommon vascular origins, particularly from coronary arteries, is important to avoid injury and possible ischemia, infarction, exsanguination, or death.

Fissureless lobectomy.

Traditional lobectomy techniques describe division of pulmonary parenchyma within the fissures for access to the pulmonary artery. This results in air leaks, which may prolong chest tube drainage and hospitalization times. We describe a technique for lobectomy in which all lung parenchyma is divided using a stapler.

Posterior ventricular septal rupture: an anatomical reconstruction.

Rupture of the ventricular septum following posterior myocardial infarction is an uncommon, but lethal, injury that requires prompt repair. Surgical reconstruction can be complex, demanding, and unfamiliar. Conventional techniques, as described in the literature, are associated with a variety of potential pitfalls. An alternative method we have successfully used in our last four patients is presented in detail. The procedure uses two composite (felt/pericardium) patches: an internal patch to reconstruct the left ventricular geometry and an external patch to repair the subtotal infarctectomy. For maximal security, all suture lines sandwich myocardium between two continuous felt surfaces. Specific transition stitches are described, which reliably anchor the entire repair at the critical, but poorly visualized, areas where the ventricular septum makes its transition to left and right ventricular free walls. This technique offers immediate hemostasis and a more anatomical left ventricular geometry. The method also reduces the risk of systemic thromboembolism, residual VSD, and repair disruption.

Videothoracoscopic treatment of hepatic hydrothorax.

Hepatic hydrothorax occurs frequently in ascites arising from communications in the diaphragm between peritoneal and pleural cavities. Numerous treatments have been described but are of limited utility due to invasiveness and poor success rate. We describe a case of hepatic hydrothorax in which the pore in the diaphragm was documented photographically and in which successful resolution was achieved with videothoracoscopic suture ligation and talc pleurodesis.

Head, face, and neck trauma from large animal injury in New Mexico.

BACKGROUND: Head, face, and neck injuries (HFNI) occur during animal-related trauma. We compared patients with HFNI and without HFNI after animal-related injuries to determine the significance of these injuries. METHODS: Retrospective review of admissions for animal injuries between January 1, 1990, and December 31, 1995, by age, gender, mechanism, animal, Glasgow Coma Scale (GCS) score, Injury Severity Score (ISS), Abbreviated Injury Severity score for head and neck (AIS Head/Neck), AIS score for face (AIS Face), intensive care unit stay, hospitalization length, morbidity, and mortality. RESULTS: There were 153 admissions: 61 HFNI and 92 no HFNI. Significant differences occurred in gender, animal, activity, GCS, and ISS. HFNI had higher AIS Head/Neck, AIS Face, and mortality. HFNI were from horses in 87% and occurred during recreation in 89%; 39% of patients with HFNI were 18 years or younger. CONCLUSION: HFNI occur in females and young people and produce lower GCS score, higher ISS, higher AIS Head/Neck, higher AIS Face, and higher mortality. Most occur during recreational horseback riding. Protective headgear should be mandated.