Descending Necrotizing Mediastinitis by Streptococcus anginosus and Prevotella buccae in an Intensive Care Unit Patient: A Case Report.

Necrotizing infections of deep neck spaces are a group of life-threatening infectious diseases acquired through trauma or as a descending infection from an odontogenic source. The isolation of pathogens is unusual because of the anaerobic nature of the infection; however, one way to achieve this is through the use of automated microbiological methods like matrix-assisted laser desorption/ionization and time-of-flight (MALDI-TOF) following standard microbiology protocols for analyzing samples from potential anaerobic infections. We present a case of a patient without risk factors for descending necrotizing mediastinitis with isolation of Streptococcus anginosus and Prevotella​​​​​​​ buccae managed at the intensive care unit with a multidisciplinary team. We present our approach and how we successfully treat this complicated infection.

Red neural artificial para predecir factores de riesgo asociados a complicaciones postoperatorias secundarias al tratamiento del neumotórax / Artificial neural network to predict risk factors associated with postoperative complications secondary to pneumothorax treatment

Introducción. Debido a la ausencia de modelos predictivos estadísticamente significativos enfocados a las complicaciones postoperatorias en el manejo quirúrgico del neumotórax, desarrollamos un modelo, utilizando redes neurales, que identifica las variables independientes y su importancia para reducir la incidencia de complicaciones. Métodos. Se realizó un estudio retrospectivo en un centro asistencial, donde se incluyeron 106 pacientes que requirieron manejo quirúrgico de neumotórax. Todos fueron operados por el mismo cirujano. Se desarrolló una red neural artificial para manejo de datos con muestras limitadas; se optimizaron los datos y cada algoritmo fue evaluado de forma independiente y mediante validación cruzada, para obtener el menor error posible y la mayor precisión con el menor tiempo de respuesta. Resultados. Las variables de mayor importancia según su peso en el sistema de decisión de la red neural (área bajo la curva 0,991) fueron el abordaje por toracoscopia video asistida (OR 1,131), el uso de pleurodesis con talco (OR 0,994) y el uso de autosuturas (OR 0,792; p<0,05). Discusión. En nuestro estudio, los principales predictores independientes asociados a mayor riesgo de complicaciones fueron el neumotórax de etiología secundaria y el neumotórax recurrente. Adicionalmente, confirmamos que las variables asociadas a reducción de riesgo de complicaciones postoperatorias tuvieron significancia estadística. Conclusión. Identificamos la toracoscopia video asistida, el uso de autosuturas y la pleurodesis con talco como posibles variables asociadas a menor riesgo de complicaciones. Se plantea la posibilidad de desarrollar una herramienta que facilite y apoye la toma de decisiones, por lo cual es necesaria la validación externa en estudios prospectivos

Introduction. Due to the absence of statistically significant predictive models focused on postoperative complications in the surgical management of pneumothorax, we developed a model using neural networks that identify the independent variables and their importance in reducing the incidence of postoperative complications. Methods. A retrospective single-center study was carried out, where 106 patients who required surgical management of pneumothorax were included. All patients were operated by the same surgeon. An artificial neural network was developed to manage data with limited samples. The data is optimized and each algorithm is evaluated independently and through cross-validation to obtain the lowest possible error and the highest precision with the shortest response time. Results. The most important variables according to their weight in the decision system of the neural network (AUC 0.991) were the approach via video-assisted thoracoscopy (OR 1.131), use of pleurodesis with powder talcum (OR 0.994) and use of autosutures (OR 0.792, p<0.05). Discussion. In our study, the main independent predictors associated with a higher risk of complications are pneumothorax of secondary etiology and recurrent pneumothorax. Additionally, we confirm that the variables associated with a reduction in the risk of postoperative complications have statistical significance. Conclusion. We identify video-assisted thoracoscopy, use of autosuture and powder talcum pleurodesis as possible variables associated with a lower risk of complications and raise the possibility of developing a tool that facilitates and supports decision-making, for which external validation in prospective studies is necessary

Terapia de presión negativa para pacientes con enfisema subcutáneo y neumomediastino masivo / Negative pressure therapy for patients with subcutaneous emphysemaand massive pneumomediastinum

Se han descrito diversas técnicas para el tratamiento del enfisema subcutáneo y del neumomediastino. Algunos pacientes con pequeñas perforaciones traqueales pueden ser manejados de forma expectante, salvo que requieran ventilación mecánica. Se presentan las imágenes de un paciente con enfisema subcutáneo y neumomediastino no candidato a cirugía y quien fue tratado exitosamente con terapia de presión negativa.

Different techniques have been described for the treatment of subcutaneous emphysema and pneumomediatinum. Some patients with small tracheal perforations can be managed expectantly, unless they require mechanical ventilation. Images of a patient with subcutaneous emphysema and pneumomediastinum not a candidate for surgery and who was successfully treated with negative pressure therapy are presented.

Videotoracoscopia para el diagnóstico y tratamiento de los empalamientos por cuchillo en el tórax / Video-assisted thoracoscopy in the diagnosis and treatment of stab wounds in the chest

No disponible

Pericardioscopy for diagnosing penetrating cardiac trauma.

Currently, the diagnosis of hemopericardium in trauma is made mainly by ultrasonography. A pericardial window, either through thoracoscopy or by a subxiphoid approach, is also used. However, hemopericardium per se might be overly sensitive for diagnosing cardiac injuries after chest trauma. The use of diagnostic pericardioscopy in a hemodynamically stable patient with penetrating cardiac trauma is presented. This procedure excluded significant cardiac injury and spared the patient from a major nontherapeutic procedure.

Traumatic thoracobiliary (pleurobiliary and bronchobiliary) fistula.

BACKGROUND: Traumatic thoracobiliary fistula is a rare but serious complication. A series of thoracobiliary fistulas secondary to penetrating trauma and analysis of trends in management are presented. METHODS: We retrospectively reviewed all patients with traumatic thoracobiliary fistula, treated from April 2008 to February 2010. There were 5 patients: 4 suffered gunshot wounds and 1 was stabbed. The mean injury severity score was 22. RESULTS: Initial treatment was insertion of a chest tube in all cases. One patient underwent damage-control surgery and hepatic packing, and 3 were managed with laparotomy, a perihepatic closed drain, and suture of the diaphragm. Two patients developed bronchobiliary fistulas and 3 had pleurobiliary fistulas. Diagnostic procedures involved determination of bilirubin in pleural effusion, computed tomography, magnetic resonance cholangiography, hepatobiliary iminodiacetic scans, and endoscopic retrograde cholangiography. Definitive treatment included sphincterotomy and stenting in 4 cases, pulmonary decortication in 5, fistulectomy in 2, hepatic suture in 2, perihepatic closed drain placement in 4, and suture of the diaphragm in 4. CONCLUSIONS: Traumatic thoracobiliary fistulas are complex lesions. A multidisciplinary approach is required for a timely and successful outcome. Endoscopic retrograde cholangiography is very useful as the initial procedure to confirm the diagnosis and also for treatment.

Uso de colgajos musculares en las perforaciones traumáticas del esófago / Use of muscular flaps to repair traumatic esophageal perforations: report of two cases

The management of esophageal perforations is variable, ranging from conservative management to esophageal excision. Muscular flaps are used specially when there are associated lesions in trachea or aorta. We report two patients managed using this last technique. A 31 years old woman that received a gun shot in the neck that was operated, repairing two tracheal and two esophageal perforations. The patient had to be reoperated 28 days later, due to a dehiscence of the esophageal suture. A muscular flap was used to repair the lesion with a good postoperative evolution. A 17 years old male that received a gunshot in the left supraclavicular region. Eight days later, he was operated, draining a right empyema and repairing an esophageal perforation using a muscular flap. The patient had a good postoperative evolution.

Las perforaciones del esófago, especialmente las de manejo tardío, representan un dilema y un reto para el cirujano. El manejo de las perforaciones tardías ha sido controversial y las opciones terapéuticas incluyen desde manejo conservador y simple drenaje hasta la resección del esófago. Se presentan 2 casos de perforaciones esofágicas producidas por proyectil de arma de fuego referidos a los 28 y 8 días respectivamente. En ambos se realizó reparación primaria reforzada con colgajo muscular.

Open thoracotomy and decortication for chronic empyema.

OBJECTIVES: Traditionally, chronic empyema has been treated by thoracotomy and decortication. Some recent reports have claimed similar clinical results for videothoracoscopy, but with less morbidity and mortality than open procedures. Our experience with thoracotomy and decortication is reviewed so that the results of this surgical procedure can be adequately evaluated. MATERIALS AND METHODS: From March 1992 to June 2006, 85 patients diagnosed with empyema were treated at Santo Tomás Hospital by the first author. Diagnosis of chronic empyema was based on the duration of signs and symptoms before definitive treatment and imaging findings, such as constriction of the lungs and the thoracic cage. Thirty-three patients fulfilled the criteria for chronic empyema and underwent open thoracotomy and decortication. RESULTS: Twenty-seven patients (81.8 %) were male and the average age of the study group was 34 years. The etiology was pneumonia in 26 patients (78.8%) and trauma in 7 (21.2%). The duration of symptoms and signs before definitive treatment averaged 37 days. All patients had chronic empyema, as confirmed by imaging studies and operative findings. Surgery lasted an average of 139 min. There were 3 (9%) complications with no mortality. The post-operative length of stay averaged 10 days. There were no recurrences of empyema. CONCLUSIONS: Open thoracotomy and decortication can be achieved with low morbidity and mortality. Long-term functional results are especially promising. We suggest that the validation of other surgical approaches should be based on comparative, prospective and controlled studies.

Open thoracotomy and decortication for chronic empyema

OBJECTIVES: Traditionally, chronic empyema has been treated by thoracotomy and decortication. Some recent reports have claimed similar clinical results for videothoracoscopy, but with less morbidity and mortality than open procedures. Our experience with thoracotomy and decortication is reviewed so that the results of this surgical procedure can be adequately evaluated. MATERIALS AND METHODS: From March 1992 to June 2006, 85 patients diagnosed with empyema were treated at Santo Tomás Hospital by the first author. Diagnosis of chronic empyema was based on the duration of signs and symptoms before definitive treatment and imaging findings, such as constriction of the lungs and the thoracic cage. Thirty-three patients fulfilled the criteria for chronic empyema and underwent open thoracotomy and decortication. RESULTS: Twenty-seven patients (81.8 percent) were male and the average age of the study group was 34 years. The etiology was pneumonia in 26 patients (78.8 percent) and trauma in 7 (21.2 percent). The duration of symptoms and signs before definitive treatment averaged 37 days. All patients had chronic empyema, as confirmed by imaging studies and operative findings. Surgery lasted an average of 139 min. There were 3 (9 percent) complications with no mortality. The post-operative length of stay averaged 10 days. There were no recurrences of empyema. CONCLUSIONS: Open thoracotomy and decortication can be achieved with low morbidity and mortality. Long-term functional results are especially promising. We suggest that the validation of other surgical approaches should be based on comparative, prospective and controlled studies.

Divertículo epifrénico Descripción de un caso clínico y revisión de la literatura / Epiphrenic diverticulum. A clinical case and literature review

El divertículo epifrénico es una patología poco frecuente. La etiología y el tratamiento han sido motivo de controversia a través de los años. Se presenta el caso de un paciente con divertículo epifrénico con síntomas incapacitantes que fue sometido a diverticulectomía y esofagomiotomía. Se discuten la etiología, el diagnóstico y tratamiento.

Tumor fibroso solitario de pleura / Solitary fibrous tumor of the pleura

No disponible

Surgical treatment of traumatic esophageal perforations: analysis of 10 cases.

PURPOSE: Traumatic esophageal perforations are infrequent. They represent a surgical dilemma for surgeons, especially if diagnosis is made late. Recently, it has been reported that mortality due to perforation of the esophagus has diminished independently of time of presentation. The experience with traumatic perforations of the esophagus is reviewed to determine morbidity-mortality and how it is affected by time. METHODS: A retrospective clinical review was made of all patients with a diagnosis of traumatic perforation of the esophagus treated by the author. There were 10 patients, all of them male. Average age was 32 years (range 17 to 63). The cause of trauma was gunshot (7), blunt trauma (1) and foreign body (2). Four patients were treated within 24 hours of injury (early treatment). Treatment of 6 patients was delayed 56 to 168 hours after the injury (delayed treatment). RESULTS: Patients treated early underwent primary repair. Delayed treatment included: primary repair (1), T-tube (2), drainage of cervical abscess and pulmonary decortication (2), and conservative treatment (1). There was 1 death in the delayed group (16.6%). One patient in the early treatment group (25%); 4 (66%) in the delayed treatment group had complications. Postoperative stay in the hospital was an average of 20.5 days for the early treatment group and 38 for the late treatment group. CONCLUSIONS: Mortality of traumatic esophageal perforations has diminished significantly. Morbidity, particularly in delayed treatment, is still very high, with multiple operations and prolonged stays in intensive care units and surgical wards, resulting in high hospital costs. The main factor that seems to influence mortality-morbidity of traumatic esophageal perforations is the time of diagnosis. Every effort should be made to diagnose these injuries early. Once diagnosis is made, treatment should be aggressive and expeditious.

Surgical treatment of traumatic esophageal perforations: analysis of 10 cases

PROPÓSITO: Perfurações esofágicas não são freqüentes. Representam um dilema cirúrgico, especialmente se o diagnóstico é tardio. Relato recente dá conta que a mortalidade devida a perfuração esofágica apresenta redução independentemente de seu tempo de evolução. A experiência com perfurações esofágicas traumáticas é aqui revista para determinar a relação morbi-mortalidade e como esta é afetada pelo tempo. MÉTODOS: Uma revisão retrospectiva clínica foi realizada para todos os pacientes com diagnóstico de perfuração esofágica traumática tratados pelo autor. Registraram-se 10 pacientes, todos do sexo masculino. I idade média foi de 32 anos (17 a 63). As causas foram arma de fogo (7), trauma contuso (1) e corpo estranho (2). Quatro pacientes foram tratados até 24 horas após o trauma (tratamento precoce), enquanto os outros 6 foram tratados 56 a 168 horas pós trauma (tratamento tardio). RESULTADOS: Os pacientes tratados precocemente evoluíram com reparo primário. Os pacientes em tratamento tardio incluíram: reparo primário (n=1), tubo-T (n=2), drenagem de abscesso cervical e decorticação pulmonar (n=2), tratamento conservador (n=1). Foi registrado 1 óbito no grupo tardio (16,6%). Um paciente no grupo precoce (25%) e 4 (66%) no grupo tardio registraram complicações. O tempo médio de permanência hospitalar pós-operatória foi de 20.5 dias para o grupo precoce e de 38 dias para grupo tardio. CONCLUSIONS: A mortalidade resultante de perfurações esofágicas traumáticas reduziu-se significativamente. A morbidade permanece elevada, especialmente em pacientes tratados tardiamente, com cirurgia múltipla e períodos prolongados de hospitalização em unidades de terapia intensiva e enfermarias cirúrgicas, do que resultam elevados custos hospitalares. Aparentemente, o principal fator responsável pela morbi-mortalidade é o tempo de diagnóstico. Todos os esforços deveriam ser investidos no diagnóstico precoce. Uma vez feito o diagnóstico, o tratamento deve ser urgente e agressivo.

Toracoscopía rígida en el manejo del hemotórax traumático coagulado / Rigid thoracoscopy in the management of clotted traumatic hemothorax

Introducción: El tratamiento moderno del hemotórax traumático coagulado implica su evacuación temprana y el uso de técnicas mínimamente invasivas. El objetivo de este trabajo es evaluar el resultado de la toracoscopía rígida o sin video en la evacuación del hemotórax coagulado traumático. Material y métodos: Estudio descriptivo, prospectivo de 15 enfermos, 13 hombres y 2 mujeres con edad promedio de 25.5 años en los que se realizó evacuación de hemotórax traumático coagulado de siete o menos días de evolución mediante toracoscopía rígida con mediastinoscopio de Carlens. La operación se llevó a cabo por una o dos incisiones de 2.5 cm. En ninguno se utilizó intubación endotraqueal de doble luz. Resultados: La etiología fue de heridas por arma blanca en 9, proyectil de arma de fuego en 5 y en 1 por trauma cerrado. Además del hemotórax coagulado se encontraron perforación del diafragma en 3, laceración hepática en 1, y laceración pulmonar en otro. Se realizó incisión accesoria en 4 y una fue convertida a toracotomía limitada por dificultad técnica. El tiempo quirúrgico promedio fue de 53.3 min. No hubo mortalidad y la morbilidad fue 1 caso de neumonía (6.6%). El promedio de estancia posoperatoría fue de 3.8 días. El costo estimado fue de 528 dólares americanos. Conclusiones: La toracoscopía rígida con mediastinoscopio de Carlens es un excelente método para evacuar el hemotórax traumático coagulado, con las ventajas de simplicidad en el equipo, menor costo y no necesitar intubación endotraqueal de doble luz. El procedimiento debe ser considerado en el manejo del hemotórax coagulado traumático de siete días o menos de evolución.

Introduction: Modern treatment of clotted traumatic hemothorax involves early evacuation and the use of minimally invasive techniques. The objective of this paper is to evaluate the results of rigid non-video thoracoscopy in the management of clotted traumatic hemothorax. Material and methods: In this prospective work, 15 consecutive patients, 13 men and 2 women, average age 25.5 years, were submitted to evacuation of a clotted traumatic hemothorax within 7 days or less of injury by means of rigid non-video thoracoscopy with a Carlens mediastinoscope through 1 or 2 one inch incisions under general anesthesia using a single lumen endotracheal tube. Results: Etiology were stab wounds in 9, gunshot wounds in 5 and blunt trauma in 1. Associated findings were diaphragmatic perforations in 3, hepatic laceration in 1 and pulmonary laceration in 1. An accessory incision was necessary in 4 cases, and 1 patient was converted to a limited thoracotomy due to technical difficulties. Average surgical time was 53.3 min. There was no mortality; one patient developed pneumoniae (6.6%). Average post-operative stay was 3.8 days. Estimated cost was 528 US dlls. Conclusions: Rigid non-video thoracoscopy using a Carlens mediastinoscope is an excellent method for the evacuation of clotted traumatic hemothorax with the advantages of simplicity of the equipment, diminished costs and the avoidance of double lumen endotracheal intubation. Rigid thoracoscopy should be considered in the management of short term, seven days or less, clotted traumatic hemothorax.