Isolated sternal fractures treated on an outpatient basis.

AIM: The aim of this study is to investigate the need for admission of patients with isolated sternal fracture (ISF) by prospectively and randomly discharging or admitting them. METHODS: Patients with ISF after the completion of investigations were randomly discharged or admitted. Investigations performed included lateral chest x-ray; chest computed tomography; electrocardiogram; cardiac ultrasound; definition of C-reactive protein; and cardiac enzymes, such as creatine phosphokinase, myocardial branch of creatine phosphokinase, and troponin I (cardiac specific). These investigations were repeated after 6 hours in the admission and the next day in both groups. RESULTS: Forty-two patients were included in the study. Twenty-one were admitted, whereas 21 were discharged. Electrocardiogram and ultrasound were normal in both groups upon presentation and the next day. Creatine phosphokinase and myocardial branch of creatine phosphokinase, although elevated at presentation, were normal the next day and similar in both groups. There was no morbidity, need for surgery, or mortality in both groups during a 6-month follow-up. CONCLUSIONS: Patients with ISF can be discharged safely as soon as investigations are completed. Extensive myocardial assessment is not needed on the posttraumatic period. Myocardial involvement seems unlikely in patients with ISF, who can be treated with oral analgesics.

Nonsteroidal anti-inflammatory drugs alter the human mesothelial pleural permeability via ion cellular transportation by inhibiting prostaglandin synthesis.

BACKGROUND: Nonsteroidal anti-inflammatory drugs (NSAIDs) are used in clinical practice as analgesics or anti-inflammatory drugs. Studies have implicated them in participating in permeability throughout various tissues such as the kidneys and lungs. OBJECTIVE: The effect of NSAIDs on the pleural permeability and the underlying mechanisms whereby this effect is mediated were investigated. METHODS: Parietal pleural specimens were obtained from patients subjected to thoracic surgery and were mounted in Ussing chambers. Solutions containing paracetamol, acetylsalicylic acid, diclofenac, lornoxicam, parecoxib and ibuprofen were added in the chambers facing the pleural and the outer-pleural surface. Prostaglandin E(2) was similarly used to investigate prostaglandin synthesis involvement at low and high doses. Amiloride- and ouabain-pretreated specimens were used in order to investigate ion transportation involvement. Transmesothelial resistance (R(TM)) was determined as a permeability indicator. RESULTS: Paracetamol, acetylsalicylic acid, diclofenac, lornoxicam and ibuprofen increased R(TM) on the pleural and outer-pleural surface, inhibited by amiloride and ouabain. Parecoxib had no effect on the R(TM). Prostaglandin decreased R(TM) on the pleural and outer-pleural surface inhibited by amiloride, ouabain and ibuprofen. CONCLUSION: NSAIDs, except parecoxib, induce a rapid decrease of the pleural permeability by inhibiting cellular transportation, an effect that is mediated by prostaglandin synthesis inhibition.

Pleural Pressure Differences Before Removal Are Greater in Patients Who Develop Residual Pneumothorax Post Chest Drain Removal.

Aim of study: We aimed to investigate whether the difference in pleural pressures (ΔP) is wider among patients who develop a residual pneumothorax after chest tube removal following lung resection surgery. Materials and methods: Ninety-eight patients who underwent lung resection were included in the study over a period of 12 months. The ΔP prior to chest tube removal in patients who developed a residual pneumothorax after chest tube removal was compared with that of patients who did not develop this complication. The receiver operating characteristic (ROC) curve analysis was performed to identify cutoff values of ΔP for the prediction of residual pneumothorax. Logistic regression analysis was used to formulate a prediction model for the occurrence of residual pneumothorax based on ΔP. Results: Thirteen patients who developed a residual pneumothorax were compared with 85 patients without this complication. The ΔP in the residual pneumothorax group was significantly higher (10.8 versus 4.2 cm H2O, p < 0.01). The ΔP in patients who required intervention was also significantly higher (14.8 versus 4.2 cm H2O, p < 0.01). A ΔP cutoff value of 8 cm H2O was predictive of the occurrence of residual pneumothorax (sensitivity 85.6%, specificity 84.6%) and a value of 12 cm H2O was predictive of intervention (sensitivity 84%, specificity 85%). Increasing ΔP was an independent predictor of the occurrence of residual pneumothorax (p = 0.008) on the multivariate logistic regression model. Conclusion: Patients with wide ΔP before chest drain removal may be complicated with residual pneumothorax.

Late presentation of jejunal perforation after thoracic trauma.

Jejunal perforation is extremely rare in trauma especially without initial involvement of the abdomen. We present the case of a delayed jejunal perforation after thoracic trauma with no initial indication of abdominal trauma in a 55-year-old man who was admitted to our department after a road traffic accident. The patient sustained thoracic trauma with rib fractures of the left hemithorax and hemopneumothorax and a mild head injury. On the fourth day of his in-hospital stay, he complained of severe abdominal pain and signs of acute abdomen were observed. He underwent emergency laparotomy where a perforation of the jejunum near the ligament of Treitz was noticed and sutured. His postoperative recovery was uneventful. Physicians treating trauma should always have a high degree of suspicion regarding rare abdominal injuries, with delayed presentation, even if no abdominal involvement is noticed during the initial survey.

Ipsilateral pulmonary infarction after major lung resection.

Background Lung infarction is a rare complication of lung resection, developing mainly because of technical errors. In some cases, a specific reason cannot be identified. This study aimed to investigate the occurrence, characteristics, and outcome of this pathology in a series of patients. Methods The medical records of patients who underwent reoperation for lung infarction without an apparent cause (based on imaging, reoperation findings, and histopathology) after major lung resection at our institution from 2006 to 2015, were investigated. Results Seven patients were identified. The mean age was 62.2 years (range 51-75 years), and 5 were male. Copious dissection or adverse events during surgery were recorded in all but 2 cases. The main presenting symptom was unsettling frank hemoptysis (4 cases) with a variable time of onset of symptoms (4-164 h). All reoperations necessitated further lung resection (4 patients had a further lobectomy and 3 had a completion pneumonectomy). During reoperation, all vessels and bronchi were intact. No apparent cause of infarction could be identified according to the histopathology report. Morbidity after reoperation was atrial fibrillation in 3 cases and bronchopleural fistula in 2, one of which required a transsternal pneumonectomy and this was the only mortality. Length of stay ranged from 8 to 90 days. Conclusion Ipsilateral lung infarction after lobectomy is a rare complication and the reason may not be identifiable. Treatment usually requires reoperation. Extensive manipulation or adverse events during surgery could induce this rare complication.

Do pleural adhesions influence the outcome of patients undergoing major lung resection?

OBJECTIVES: Our goal was to investigate whether pleural adhesions identified during an operation can induce adverse events. We investigated the outcome of major lung resection in patients with pleural adhesions encountered on entry into the pleural cavity. METHODS: We conducted a retrospective analysis of 144 patients undergoing major lung resection over a period of 9 months. Recorded data included demographics, comorbidities, surgical data, fluid volume drainage (on postoperative days [POD] 1 and 2 and in total), the overall and pleural space-associated morbidity (empyema, prolonged air leak or drainage, space issues), 30-day and late mortality rates. Patients were grouped according to the presence or not of adhesions observed when we entered the chest. RESULTS: Differences between patients without versus patients with adhesions were recorded for operative time (138 vs 169.3 min, P < 0.02), postoperative drainage on POD1 and POD2 (328.6 vs 478.5 ml, P < 0.01 and 214 vs 378 ml, P < 0.01 respectively), duration of air leak (1 vs 2 days, P = 0.03), duration of chest tube stay (2 vs 4 days, P < 0.01) and pleural morbidity (21.1% vs 38.8%, P = 0.02). There were no differences recorded in the 2 groups on conversion rates (2.5% vs 14.3%, P = 0.46), 30-day (1.1% vs 4.1%, P = .73) and late deaths (log-rank, P = 0.70). Pleural morbidity differed if the chest tube was removed on or earlier than POD2 (57.9% vs 36.9%, P = 0.02). We also calculated differences between those patients with adhesions involving the lower chest (55.1%) versus the rest of the group and specifically drainage on POD1 and POD2 (540.9 vs 372.1 ml, P < 0.01 and 392.5 vs 261 ml, P = 0.02, respectively) and pleural morbidity (46.4% vs 28.6%, P < 0.01). Logistic regression identified that firm, extensive adhesions, present in the lower third of the pleural cavity, are important predictors of pleural morbidity. CONCLUSIONS: Patients undergoing major lung resection who have pleural adhesions have an increased incidence of adverse surgical outcomes and higher pleural morbidity.

Delayed presentation of aortoesophageal fistula after endovascular repair.

The incidence of aortoesophageal fistula after thoracic endovascular aortic repair has increased following an increase in thoracic endovascular aortic procedures. A 68-year-old man was diagnosed with aortoesophageal fistula 6 years after thoracic endovascular aortic repair of a descending aortic aneurysm. Due to massive hematemesis and instability, he underwent a left thoracotomy, graft repair of the aorta with stent removal, gastrostomy, and proximal esophagostomy. Unfortunately, he died 1 week later due to sepsis. Aortoesophageal fistula may present long after thoracic endovascular aortic repair, and clinicians treating such cases should always be aware of this complication.

Performance of wider parenchymal lung resection than preoperatively planned in patients with low preoperative lung function performance undergoing video-assisted thoracic surgery major lung resection.

OBJECTIVES: Pulmonary assessment before major lung resections is used to determine patient's operability. In marginal cases, extensive pulmonary assessment is additionally important under the fear of a more radical parenchymal removal. This study investigates the outcome of wider lung parenchymal resections in patients with low lung functional status undergoing video-assisted thoracic surgery (VATS) major lung resection. METHODS: The medical records of patients who underwent VATS major lung resection for cancer, over a period of 5 years (August 2009-August 2014), were retrospectively reviewed. Patients with postoperative forced expiratory volume in first second (ppoFEV1) or postoperative diffusional capacity for carbon monoxide (ppoDLCO) <40% who underwent wider lung resection than preoperatively planned (Group A) were compared with patients with ppoFEV1 or ppoDLCO <40% who underwent the planned operation (Group B) and patients with ppoFEV1 and ppoDLCO >40% who underwent wider resection than preoperatively planned (Group C). Data analysed included demographics, past medical history, the surgery planned and performed, the reason for higher parenchymal resection, the clinical and pathological stage, the length of stay (LOS), the morbidity, the 30-day mortality and the survival. RESULTS: Overall, 73 patients were analysed (15 patients in Group A, 50 patients in Group B and 8 patients in Group C). The mean age was 68.5 years and 31.5% were males. The wider lung resection regarded 7 patients who underwent bilobectomy instead of lobectomy and 16 patients who underwent pneumonectomy instead of lobectomy. The main reason for higher resection was the wider invasion of the mass (21 patients). The age, gender and body mass index between three groups were similar, whereas ppoFEV1 and ppoDLCO were different (P < 0.001 and P < 0.001 respectively). Conversions, pulmonary morbidity and the 30-day mortality between groups were similar (P = 0.67, P = 0.88 and P = 0.33, respectively). LOS between groups was not different (P = 0.46). Survival rate between groups was also similar (log-rank, P = 0.79). CONCLUSIONS: Wider lung parenchymal resection than preoperatively anticipated may be performed, even in patients with low lung functional status, without increased adverse outcome when compared with patients with good lung function. This finding indicates that the preoperative risk stratification based on lung function tests is questionable.

Paracetamol and ibuprofen block hydrothorax absorption in mice.

OBJECTIVES: Non-steroidal anti-inflammatory agents (NSAIDs) and paracetamol alter pleural permeability, hindering pleural fluid recycling. The aim of this study was to investigate the effect of different analgesic and anti-inflammatory agents on fluid recycling in an induced hydrothorax model in mice. METHODS: Hydrothorax was induced in C57BL/6 mice by injecting 500 µl phosphate-buffered saline-bovine serum albumin 1% isosmotic in the right hemithorax. Paracetamol (1 g/kg), ibuprofen (250 mg/kg) and parecoxib (2 mg/kg) were administered systematically by intraperitoneal injections. Each drug group included eight mice, which were sacrificed at 2 h and 4 h, respectively, after injections. The remaining hydrothorax volume and total cells contained were determined. RESULTS: Regarding the paracetamol and ibuprofen groups, the remaining hydrothorax volume was greater than in the control group (350 ± 61, 348 ± 62 and 270 ± 51 µl, respectively, P = 0.042) when mice were sacrificed within 2 h. Similar observations were made in groups sacrificed after 4 h (202 ± 45 and 198 ± 44 vs 107 ± 56 µl, respectively, P = 0.002). In the parecoxib group, the remaining hydrothorax volume was 122 ± 53 µl (P = 0.038 versus paracetamol and ibuprofen, P > 0.05 versus control group). At the same time, the absorption rate in the paracetamol and ibuprofen groups was lower than in the parecoxib and control groups (P = 0.033). In the parecoxib group, the absorption rate was lower than that in the control group after 2 h (P = 0.042). In the paracetamol and ibuprofen groups, the total cell count and the macrophage and the neutrophils counts were increased, compared with the control and parecoxib groups (P = 0.025, 0.028 and 0.032, respectively). CONCLUSIONS: Paracetamol and ibuprofen acutely hinder pleural fluid recycling by lowering the fluid absorption rate (higher remaining hydrothorax volume), while they increased total white cell counts. COX-2s presented lower remaining hydrothorax volume without acutely increasing the absorption rate. These findings could present some relevance to the administration of painkillers in patients with pleural effusion after thoracotomy.

Usefulness of colchicine to reduce perioperative myocardial damage in patients who underwent on-pump coronary artery bypass grafting.

The objective of the present study was to test whether a perioperative course of colchicine, in patients who underwent standard coronary artery bypass grafting, would result in reduced postoperative increase of myocardial injury biomarker levels. Patients were prospectively randomized to colchicine or placebo starting 48 hours before scheduled coronary artery bypass grafting and for 8 days thereafter (0.5 mg twice daily). The primary outcome parameter was maximal high-sensitivity troponin T (hsTnT) concentration within 48 hours after surgery. Secondary outcome measures were maximal creatine kinase-myocardial brain fraction (CK-MB) levels and area under the curve (AUC) of hsTnT and CK-MB concentrations; 59 patients were included. Maximal hsTnT was 616 pg/ml (396 to 986) in the colchicine group versus 1,613 pg/ml (732 to 2,587) in controls (p = 0.002). Maximal CK-MB was 44.6 ng/ml (36.6 to 68.8) and 93.0 ng/ml (48.0 to 182.3), respectively (p = 0.002). The median AUC for hsTnT was 40,755 pg h/ml (20,868 to 79,176) in controls versus 20,363 pg h/ml (13,891 to 31,661) in the colchicine group (p = 0.002). AUCs for CK-MB were 2,552 ng h/ml (1,564 to 4,791) in controls and 1,586 ng h/ml (1,159 to 2,073) in the colchicine group (p = 0.003). The main complaints associated with colchicine were, as expected, gastrointestinal, with 5 patients (16.7%) in the colchicine group reporting diarrhea versus 1 control (3.4%) (p = 0.195). In conclusion, a short perioperative course of colchicine was effective in attenuating postoperative increases of hsTnT and CK-MB compared with placebo. This finding, which needs confirmation in a larger clinical trial powered to assess clinical endpoints, suggests a potential role for this agent in reducing cardiac surgery-related myocardial damage.

Pneumomediastinum.

Pneumomediastinum is a condition in which air is present in the mediastinum. This condition can result from physical trauma or other situations that lead to air escaping from the lungs, airways or bowel into the chest cavity. Pneumomediastinum is a rare situation and occurs when air leaks into the mediastinum. The diagnosis can be confirmed via chest X-ray or CT scanning of the thorax. The main symptom is usually severe central chest pain. Other symptoms include laboured breathing, voice distortion (as with helium) and subcutaneous emphysema, specifically affecting the face, neck, and chest. Pneumomediastinum can also be characterized by the shortness of breath that is typical of a respiratory system problem. It is often recognized on auscultation by a "crunching" sound timed with the cardiac cycle (Hamman's crunch). Pnemomediastinum may also present with symptoms mimicking cardiac tamponade as a result of the increased intrapulmonary pressure on venous flow to the heart. The tissues in the mediastinum will slowly resorb the air in the cavity so most pneumomediastinums are treated conservatively.

Role of histamine in altering fluid recycling in normal and post-traumatic rabbit peritoneum.

This study aims to investigate if histamine induces electrochemical alterations in the normal and post-traumatic peritoneum. Peritoneal rabbit specimens were obtained before surgery and 10 days post-operatively and were mounted in Ussing chambers. Histamine solutions were added facing the intra-peritoneal and outer-peritoneal surface. Dimetindene maleate-, cetirizine-, and ranitidine-pretreated specimens were used to investigate histamine receptor involvement, whereas amiloride- and ouabain-pretreated specimens were used to investigate ion transportation blockage involvement. Trans-mesothelial resistance (R(TM)) was determined. Histamine-increased R(TM) intra-peritoneally and decreased it outer-peritoneally. A less intense effect was induced in post-traumatic specimens. Dimetindene maleate, cetirizine, amiloride, and ouabain totally inhibited this effect, whereas ranitidine only had a partial effect. Histamine induces electrochemical alterations in the normal and post-operative peritoneum. This effect is mediated by interaction with histamine receptors, hindering the normal process of ion trans-mesothelial transportation.

Variation of the postoperative fluid drainage according to the type of lobectomy.

OBJECTIVES: The pleural membrane of the lower pleural cavity has a greater ability to recycle fluid than the pleural membrane of the upper pleural cavity. During lobectomy, the visceral pleura is removed with the lobe, whereas the parietal pleura is traumatized during manipulation. This study investigates variations of the drainage according to the type of lobectomy and its relation to effusion-related complications. METHODS: Data of upper and lower lobectomy patients were compared with those of wedge resection patients. All patients were suctioned until totally dry before closure, and one chest tube was left in the hemithorax. The amount of fluid drained per day, the duration of drainage, the length of hospital stay and the morbidity were noted. Student's paired t-test and Mann-Whitney U-test were used for comparison; P < 0.05 was defined as statistically significant. RESULTS: Patients after lower lobectomy had more fluid drained when compared with patients after upper lobectomy or wedge resection on the first (636 ± 90, 268 ± 75 and 225 ± 62 ml, respectively; P = 0.002) and second postoperative day (464 ± 94, 237 ± 90 and 220 ± 62 ml, respectively; P = 0.046). The drainage tube was removed earlier in patients with upper lobectomy procedures than in patients with lower lobectomy procedures (4.6 ± 0.9 vs 8.1 ± 1.4 days; P = 0.014). Effusion-related complications developed in lower lobectomies with a higher output from the second postoperative day. CONCLUSIONS: A larger amount of fluid is drained after removal of the lower lobes, possibly because the important fluid-recycling ability of the lower parts of the cavity is malfunctioning. Early drainage tube removal after lower lobectomy may be reconsidered when taking into account the possibility of effusion-related complications.

IGF-1 alters the human parietal pleural electrochemical profile by inhibiting ion trans-cellular transportation after interaction with its receptor.

OBJECTIVE: The effect of IGF-1 in the human pleural permeability and the underlying mechanisms involved were investigated. DESIGN: Specimens from thoracic surgical patients were mounted in Ussing chambers. Solutions containing IGF-1 (1 nM-100 nM) and IGF-1 Receptor Inhibitor (1 µΜ), amiloride 10 µM (Na(+) channel blocker) and ouabain 1 mM (Na(+)-K(+) pump inhibitor) were used in order to investigate receptor and ion transporter involvement respectively. Trans-mesothelial Resistance (R(TM)) across the pleural membrane was determined as a permeability indicator. Immunohistochemistry for IGF-1 receptors was performed. RESULTS: IGF-1 increased R(TM) when added on the interstitial surface for all concentrations (p=.008, 1 nM-100 nM) and decreased it on the mesothelial surface for higher concentrations (p=.046, 100 nM). Amiloride and ouabain inhibited this effect. The IGF-1 Receptor Inhibitor also totally inhibited this effect. Immonuhistochemistry demonstrated the presence of IGF-1 receptors in the pleura. CONCLUSIONS: It is concluded that IGF-1 changes the electrophysiology of the human parietal pleura by hindering the normal ion transportation and therefore the pleural fluid recycling process. This event is achieved after IGF-1 interaction with its receptor which is present in the human pleura.

Staphylococcal isolated anterosuperior mediastinal abscess of unknown origin.

Mediastinal abscess is a rare presentation of infections involving the mediastinum. In rare cases, the origin of the infection cannot be identified. We report a case of a 32-year old male who was presented with a mediastinal abscess with an otherwise clear history. The origin of the infection could not be identified despite extensive investigations. The patient was operated through a cervical incision. His postoperative recovery was uneventful. Rare causes of mediastinal infections should not be overlooked from the diagnostic process even if the origin of infection cannot be identified.

Spontaneous expulsion from rectum: a rare presentation of intestinal lipomas.

Lipomas are rare, subserosal, usually solitary, pedunculated small lesions appearing mainly in the large intestine with a minimal malignancy potential. They usually run asymptomatic and become symptomatic when they become enlarged or complicated causing intestinal obstruction, perforation, intusucception or massive bleeding. In rare cases they can be self-detached and expulsed via the rectum as fleshy masses. This event mainly occurs in large, pendunculated lipomas which detach from their pedicle. The reason for this event remains in most of cases unclear although in some cases a predisposing factor does exist. Abdominal pain and obstructive ileus may be observed while in many cases bleeding occurs. The expulsed mass sets the diagnosis and in most of the cases all symptoms subside. Diagnosis is rarely established before surgery with the use of barium enema, computed tomography and colonoscopy which additionally provides measures of treatment and diagnosis. In atypical cases though, in cases where the malignancy can not be excluded or in complicated cases, surgery is recommended. Usually the resection of the affected intestinal part is adequate. If during surgery a lipoma is encountered simple lipomatectomy seems also to be adequate.

Extrathoracic chronic heamatoma presenting as a chest wall tumor 2 years after a blunt thoracic injury.

Chronic expanding heamatomas may present as masses mimicking chest wall tumors. We report the case of a patient who was presented with a giant posterior extrathoracic chest wall tumor. The mass was proven to be a chronic heamatoma possibly developed after a blunt thoracic injury which took place 2 years before presentation and was growing thereafter. Clinicians should have high suspicion of rare entities which mimic tumors and consider any information reported by the patient's history in their diagnostic process.

Isolated right diaphragmatic rupture following blunt trauma.

Blunt diaphragmatic injuries are usually caused by blunt trauma or penetrating injuries. The diagnosis may be delayed or missed because of the confusing clinical and radiographic findings and the presence of multiple associated injuries. We report the case of an isolated right diaphragm rupture in a 56-year-old man who sustained blunt thoracic trauma after car accident 2 weeks before presentation. No other injuries were detected, and he was subjected to laparotomy. Diaphragmatic rupture is perceived as an emergency entity. The late appearance of such an injury, without other accompanying injuries, is rare and should be in mind by clinicians treating trauma patients who have a delayed presentation after the injury.

Pleural electrophysiology alterations in spontaneous pneumothorax patients.

Physiology changes of the pleura in spontaneous pneumothorax (SP) patients are not known with its etiology remaining unclear. The aim of the study was to investigate the pleural electrophysiology profile of SP patients and to compare it with the normal pleural electrophysiology. Specimens from nine patients who underwent surgery for persistent SP were obtained after wedge resection (apical visceral) and apical pleurectomy (apical parietal) alongside with parietal specimens over the 8th-9th rib (caudal parietal). Specimens were mounted in Ussing chambers and trans-mesothelial resistance (R(TM)) was determined as a permeability indicator. Amiloride (Na(+) channel inhibitor) was used as an ion channel transportation inhibitor. R(TM) of apical visceral, apical parietal and caudal parietal pleura of SP patients was increased (P=0.042, 0.025 and 0.001, respectively) when compared to disease-free specimens obtained from lung lesion patients. Amiloride was unable to increase R(TM) in all cases. Histopathology of apical and caudal parietal specimens revealed inflammatory infiltration. In conclusion, pleural electrophysiology is altered in SP patients when compared with the electrophysiology of disease-free specimens. A similar observation was made for caudal pleura suggesting diffuse process that possibly involves inflammation as shown by the histopathology.