Anterior dislocation of sternoclavicular joint: A novel surgical technique.

INTRODUCTION: Anterior sternoclavicular joint dislocation (SCJ) is a relative rare injury, related to high energy trauma. The objective of the present study is to present a novel suture technique for treatment of anterior SCJ traumatic dislocation and to report clinical outcomes from a small case series undergoing this procedure. PATIENTS AND METHODS: Patients presenting with traumatic anterior SCJ disruption in our institution were eligible to participate. Surgical technique consisted of two bone tunnels drilled in vertical direction from the anterior to the posterior cortex of the manubrium. Analogous to the sternal side of the clavicle, two vertical bone tunnels were drilled from the anterior cortex towards the posterior cortex. A non-absorbable suture was passed though the four holes in a parallel configuration. Then, by pulling the free suture edges the posterior translation of the clavicle was performed. Two additional drill holes, the first in manubrium and the second in clavicle were performed from the anterior cortex to the posterior between the previous bone tunnels. A non-absorbable suture was placed in a simple configuration in order to stabilize the SCJ in the superior-inferior direction. The final follow up was 28.2 months. The mean QuickDASH was used for functional assessment. RESULTS: Seven patients (6 males and 1 female) with average age of 34,8 years were included in the present study. Two patients suffered from concomitant medial clavicle fracture. At final follow-up (none of the patients had experienced any symptoms of instability of SCJ, no side-to-side difference was observed, while the Mean QuickDASH score was 4.85. CONCLUSION: The reported technique for SCJ reconstruction in traumatic anterior SCJ dislocations with two sutures has theoretical advantages, since it stabilizes the SCJ in the antero-posterior, as well as the supero- inferior direction. Outcomes from this small case series are favorable. However, more research is desirable to compare different techniques and to conclude to the optimal surgical treatment.

Endobronchial valves in treatment of persistent air leaks: a systematic review of clinical evidence.

BACKGROUND: Persistent air leak is one of the most common complications of lung diseases and pulmonary resections. Prolonged hospitalization, increased morbidity, and increased overall treatment costs arise from persistent air leaks. The use of endobronchial valves (EBVs) in the management of air leaks is an important alternative, especially for patients who are not candidates for surgical treatment. MATERIAL/METHODS: We retrieved the included studies by performing a systematic search in PubMed and Scopus databases. The references of the included studies were also hand-searched. RESULTS: We retrieved 25 case reports and 3 case series from our literature search. The most common cause of persisting air leaks was spontaneous secondary pneumothorax (12/39, 31%). The left upper lobe (13/39, 33%) and right upper lobe (14/39, 36%) were the most frequent locations of air leaks. Most air leaks treated with EBVs ceased in less than 24 h. Three recurrences of air leak were reported and 2 cases of EBV migration were described. No deaths were reported in correlation with EBVs. CONCLUSIONS: EBVs are a minimally invasive therapeutical option that may be suitable for the treatment of persistent air leaks regardless of the initial cause, especially in high-risk patients. Nevertheless, studies with better methodological quality are essential to standardize this technique and to provide more evidence on EBV safety issues.

A large neglected pleomorphic adenoma of the lung: Report of a rare case.

Primary pleomorphic adenomas of the lung are very rare tumors that have peculiar clinical and oncologic features. We report here on the diagnostic and therapeutic approach for a patient with a large neglected pulmonary pleomorphic adenoma that presented initially as pneumonia.

Clear-cut complete rupture of origin of right main bronchus.

Complete rupture of the main bronchus after blunt thoracic trauma is rare. Most patients with blunt traumatic injury to the trachea or bronchus die before arriving at hospital. A 26-year-old man with complete right main bronchus rupture was successfully treated by urgent surgical intervention and postoperative fiberoptic bronchoscopy for bronchial toilet.

Video-thoracoscopic and open surgical management of thoracic empyema.

PURPOSE: To evaluate the outcomes of video-thoracoscopic and open surgical management of patients with thoracic empyema. METHODS: We studied 122 patients retrospectively who underwent surgery for thoracic empyema in our hospital between January, 1999 and January, 2005. Patients' medical records, surgical procedures, and outcomes were reviewed. The study identified 97 affected men and 25 affected women with a mean age of 54 years (range 16-78 years). The empyema was parapneumonic in 95 patients (78%). RESULTS: Forty-four patients who had stage II empyema underwent video-assisted thoracic surgery (VATS). The procedure was converted to thoracotomy in 13 patients (29.5%); the morbidity and mortality rates of VATS were 13% and 0, respectively. Seventy-eight patients had stage III empyema and, along with those 13 who were converted, underwent thoracotomy for decortication. The associated morbidity rate was 12%, and the mortality rate was 6.6%. Thoracotomy was considered successful in 90 of 91 patients (99%); one patient needed a reoperative thoracotomy for an organ space/surgical site infection with pus in the pleural cavity. CONCLUSIONS: Many treatment modalities are available for thoracic empyema, depending on the results of appropriate clinical and laboratory investigations. In fibrinopurulent empyema, VATS debridement is safe and effective, with minimal morbidity and no deaths. Lung decortication via thoracotomy is the only option for organized empyema and is associated with a substantial mortality rate.

Huge Extrapleural Hematoma After a Blunt Chest Trauma: An Unusual Presentation.

Massive extrapleural hematoma secondary to blunt chest trauma is exceedingly rare especially in nonanticoagulated patients. Significant amounts of blood can be sequestered between parietal pleura and the endothoracic facia leading to ventillatory and circulatory disturbances and even death. We report a case of a huge extrapleural hematoma in a non-anticoagulated 70-year-old patient secondary to blunt chest trauma. Etiology, surgical and treatment implications of this injury are briefly discussed.

Rare complications of a dental abscess.

This article describes a case involving a poorly treated odontogenic infection, which was complicated by mediastinitis, thoracic empyema, pericarditis, and ascites. A posterolateral thoracotomy was necessary as incisional surgical drainage proved to be inadequate. A multidisciplinary approach of descending necrotizing mediastinitis and its complications is essential.

Role of video-assisted thoracic surgery in the evaluation and management of thoracic injuries.

The aim of this study was to evaluate the experience of our institution with the use of video-assisted thoracic surgery (VATS) in chest trauma. Between January 1999 and September 2004, 25,213 patients presented with chest trauma to the emergency room, and 2304 were admitted to our service. Twenty-three hemodynamically stable patients (1%) underwent VATS. They were 19 men and 4 women with an average age of 42 years (range, 19-67 years). Indications included post-traumatic hemothorax in 11 patients, and post-traumatic empyema in 3, treated after 24 h of trauma. Indications for exploratory VATS in the acute phase included suspected diaphragmatic injury in 3 patients, persistent pneumothorax in 2, continued hemorrhage in 2 and removal of intrathoracic foreign body in 2. There was no mortality and complications occurred in 3 patients (13%). Management of hemodynamically stable thoracic injuries by using VATS provides diagnostic accuracy and therapeutic efficacy. It can be successfully applied in the trauma setting and surgeons should gain experience with its use.

Sports-related spontaneous pneumomediastinum.

BACKGROUND: Spontaneous pneumomediastinum is a rare medical entity occurring almost exclusively in otherwise healthy young individuals without known predisposing factors. We reported our experience with patients presenting with spontaneous pneumomediastinum related to sports. METHODS: Between January 1991 and December 2002, 10 patients were admitted with spontaneous pneumomediastinum related to sporting activities. We retrospectively reviewed their medical records with regard to predisposing factors, clinical presentation, diagnostic evaluation, and outcome. RESULTS: The mean age of our patients was 18.9 years (range 15 to 25 years). Retrosternal chest pain was the most common symptom (90%), and subcutaneous emphysema the most common physical finding (90%). Hamman's sign was present in 9 patients. In all 10 patients, physical exertion during sports was the only implicating factor (scuba diving in 4 patients, basketball in 2, soccer in 3, and volleyball in 1). All patients were treated conservatively. Complete resorption of the pneumomediastinum occurred in 3 to 8 days. Hospital stay ranged from 2 to 6 days (mean 3.8 days). Follow-up was complete in 8 patients (80%), and ranged from 6 to 84 months (mean 35 months). Only 1 recurrence of pneumomediastinum was found that was treated similarly. CONCLUSIONS: Spontaneous pneumomediastinum after sporting activities is a benign disease that generally resolves without clinical sequelae. Restriction of physical and athletic activity after the first episode is unnecessary, the only exception being that of scuba diving.

Management of descending necrotizing mediastinitis.

PURPOSE: One of the most dreaded and the most lethal form of mediastinitis is descending necrotizing mediastinitis (DNM). PATIENTS AND METHODS: Between January 1990 and June 2001, 6 patients (mean age, 54.5 years; age range, 19 to 72 years) with DNM were treated in the Department of Thoracic Surgery of General Hospital of Attica "K.A.T." The primary etiology was odontogenic abscess in 3 patients and peritonsillar abscess in the other 3. Diagnosis was confirmed by computed tomography of the neck and chest. All patients underwent surgical drainage of the involved cervical region and mediastinum by monolateral cervicotomy and left thoracotomy. RESULTS: The delay between the occurrence of thoracic symptoms and mediastinal drainage varied from 1 to 4 days. The thoracic approach and the side of the thoracotomy depended on the involved mediastinal compartments and side of pleural effusion. The duration of mediastinal drainage varied from 8 to 22 days (mean, 12.5 days). One patient died of multiorgan failure related to postoperative septic shock. CONCLUSION: Delayed diagnosis and inadequate drainage are the main causes of the high mortality rate of DNM. Routine use of the computed tomography scan is highly recommended in patients with a deep cervical infection for early detection of mediastinitis at a time when the chest roentgenogram is still normal. If one realistically hopes to avoid the high mortality rate, aggressive surgical drainage and debridement of the neck and drainage of the mediastinum via a posterolateral thoracotomy by a multidisciplinary team of surgeons are required.

Preliminary results with the use of an albumin-glutaraldehyde tissue adhesive in lung surgery.

BACKGROUND: The purpose of this study was to test the performance of an albumin-glutaraldehyde tissue adhesive, BioGlue(r) Surgical Adhesive (BioGlue) in the sealing of air leaks from pulmonary parenchyma and bronchopleural fistulas. MATERIAL/METHODS: Between March 2000 and November 2001 BioGlue was applied in 38 randomly selected patients, who underwent 39 operations. The mean age was 51.4 years (range 19 to 75 years). A median of 5 cc of BioGlue was used per patient (range 5 to 20 cc). The operations included 36 thoracotomies, 2 video-assisted thoracoscopies and one rigid bronchoscopy. RESULTS: The duration of air leak ranged from 0 to 2 days with a median of 1 day. The duration of total (air and fluid) chest tube drainage ranged from 1 to 12 days with a median of 3 days. Complications were observed in 3 patients (8%) and included atelectasis in one and residual space in 2. Three patients died because of preexisting respiratory failure unrelated to BioGlue application. Hospitalization ranged from 4 to 16 days with a median of 6 days and was prolonged in some patients because of their primary disease (empyema, bronchopleural fistula, etc.). CONCLUSIONS: The use of BioGlue proved to be safe and effective in the sealing of lung lacerations and in preventing air leakage from suture or staple lines in emphysematous lungs. It was also successful in sealing bronchopleural fistulas when applied either intra-bronchially through the rigid bronchoscope or during thoracotomy.

Experience with an albumin-glutaraldehyde tissue adhesive in sealing air leaks after bullectomy.

BACKGROUND: The purpose of this study was to evaluate the effectiveness of an albumin-glutaraldehyde tissue adhesive (BioGlue Surgical Adhesive) in preventing air leaks after bullectomy. METHODS: Between January 1999 and June 2002, BioGlue was applied over the staple or suture lines of 21 consecutive patients who underwent resection of bullae for persistent or recurrent pneumothorax. An age- and sex-matched control group of 19 bullectomy patients from our center was used for comparison. RESULTS: Air leak duration was significantly reduced in the BioGlue group (mean, 0.42 days; range, 0-2 days), compared with the control group (mean, 3.68 days; range, 2-11 days; P < .001). Chest tube drainage time was reduced to a mean of 2.33 days (range, 2-4 days) in the BioGlue group, compared with a mean of 5.42 days (range, 3-12 days) in the control group (P < .05). Morbidity and hospital stay length were slightly lower in the BioGlue group. There was no mortality or BioGlue-related complication in this patient cohort. CONCLUSIONS: The use of BioGlue as a surgical lung sealant significantly decreased the duration of postoperative air leaks and the time to chest tube removal. Use of BioGlue facilitates the postoperative course following bullectomy.