A nanomaterial-based breath test for short-term follow-up after lung tumor resection.

In this case study, we demonstrate the feasibility of nanomaterial-based sensors for identifying the breath-print of early-stage lung cancer (LC) and for short-term follow-up after LC-resection. Breath samples were collected from a small patient cohort prior to and after lung resection. Gas-chromatography/mass-spectrometry showed that five volatile organic compounds were significantly reduced after LC surgery. A nanomaterial-based sensor-array distinguished between pre-surgery and post-surgery LC states, as well as between pre-surgery LC and benign states. In contrast, the same sensor-array could neither distinguish between pre-surgery and post-surgery benign states, nor between LC and benign states after surgery. This indicates that the observed pattern is associated with the presence of malignant lung tumors. The proof-of-concept presented here has initiated a large-scale clinical study for post-surgery follow-up of LC patients. FROM THE CLINICAL EDITOR: Monitoring for tumor recurrence remains very challenging due to post-surgical and radiation therapy induced changes in target organs, which often renders standard radiological identification of recurrent malignancies inaccurate. In this paper a novel nanotechnology-based sensor array is used for identification of volatile organic compounds in exhaled air that enable identification of benign vs. malignant states.

[Thoracic nocardiosis with thoracic manifestations in two immunocompetent patients].

Nocardiosis is a rare infectious disease caused by bacteria of the genus nocardia, which causes considerable morbidity and mortality. We report two unusual cases of nocardiosis in young, immunocompetent patients; the first case involved a nocardia farcinica pulmonary and chest-wall infection, while the second was an anterior mediastinal nocardia asiaticum infection mimicking a mediastinal tumor. These cases reflect the need for a broad differential diagnosis during exploration of thoracic findings, white the potentially ambiguous presentation of nocardiosis must be considered.

Streptokinase fibrinolysis protocol: the advantages of a non-operative treatment for stage II pediatric empyema patients.

BACKGROUND: Pediatric empyema necessitates prompt resolution and early hospital discharge with minimal morbidity. However, the most effective treatment approach is not yet established. OBJECTIVES: To assess the efficacy of an intrapleural streptokinase washing protocol as a non-operative treatment for stage II pediatric empyema as compared to operative decortications, by the number of pediatric intensive care unit (PICU) admissions, length of PICU stay, and hospitalization duration. METHODS: We retrospectively evaluated 75 consecutive pediatric empyema cases for the period January 2006 to December 2009. Since July 2007 we have used repeated streptokinase-based pleural washing for stage II patients whose condition did not improve with chest drainage RESULTS: Before July 2007, 17 of 23 stage II empyema patients underwent decortication, compared to only 1 of 21 after July 2007. Non-operated children were admitted to the PICU less frequently than those who were operated (83% vs. 31%, p = 0.0006) and spent less time in the PICU (2.56 +/- 1.92 vs. 1.04 +/- 1.9 days, P= 0.0148); there was no significant statistical difference in overall hospitalization (13.33 +/- 3.69 vs.11.70 +/- 5.74 days, P= 0.301). CONCLUSIONS: Using intrapleural streptokinase washing as a non-operative treatment for stage II pediatric empyema yielded comparable success rates to the operative approach, with less morbidity.

Contralateral internal mammary silicone lymphadenopathy imitates breast cancer metastasis.

This case report presents a unique, late complication of breast reconstruction surgery. A woman, who underwent left mastectomy and several reconstruction procedures with silicone implants presented with symptomatic enlarged internal mammary lymph nodes on her contralateral side. The nodes, which were suspicious for breast cancer metastasis on positron-emission tomographic computed tomography, were removed by thoracoscopy. The histopathologic result revealed silicone adenopathy. This report is particularly interesting because it presents a rare case in which silicone has migrated to the contralateral internal mammary nodes. This complication was not previously documented in the medical literature and serves as a possible differential diagnosis to metastatic breast cancer.

Accelerated pulmonary nodulosis and sterile pleural effusion in a patient with psoriatic arthropathy during methotrexate therapy: a case report.

Pulmonary nodulosis and sterile pleural exudates are well-known extra-articular manifestations in rheumatoid arthritis patients with a positive rheumatoid factor. In some patients, treatment with methotrexate has been postulated as the trigger of these complications. We report a patient with psoriatic arthropathy, negative RF, negative anticyclic citrulinated peptide antibodies but positive antibodies to cardiolipin who developed massive sterile pleural empyema and multiple cavitary pulmonary nodules during methotrexate treatment. We suggest that awareness of methotrexate-induced lung and pleural complications should be extended to other than rheumatoid arthritis diseases, not necessarily accompanied by rheumatoid factor or anticyclic citrulinated peptide antibodies.

[Surgical management of esophageal pathology: 6 years of experience in a single surgical department].

BACKGROUND: Esophageal diseases vary in relation to geographic and behavioral factors. Whether benign or malignant, these diseases interfere with food swallowing. Surgical treatment is variable and aims at restoring the alimentary tract continuity. In this research the authors retrospectively studied esophageal pathologies and their surgical treatment in their department over a 6 year period. PATIENTS AND METHODS: The records of all patients who underwent surgery for esophageal pathology in a single surgical department at a referral center between January 2002 and December 2007 were reviewed. Data that was collected included patient age, gender, type of pathology, staging, type and length of surgery, length of hospital stay, post-operative morbidity and mortality. RESULTS: During the study period, 186 patients were operated for esophageal pathology, 154 (83%) had malignant disease and 32 (17%) had benign disease. The distribution of malignancy types was: adenocarcinoma 57%, squamous cell carcinoma 27%, signet ring cell carcinoma 8%, and other 8%. Median length of post-operative hospital stay was 27 days. Thirty two percent of the patients experienced complications, including anastomotic leak (10%), respiratory (9.5%) or cardiac (2%) complications, and infection (7.5%), while 3% required re-operation. Postoperative mortality rate in the hospital was 6.5%. CONCLUSIONS: The majority of patients undergoing esophageal surgery suffer malignancy, mainly adenocarcinoma. The surgery is extensive and is followed by a long recovery period, during which the patient is subject to a variety of complications. Mortality rate is significant yet comparable to centers around the world with high volume of esophageal operations.

Retrosternal thyroid goiter: 15 years experience.

BACKGROUND: Thyroidectomy for goiter is a common surgical procedure performed in most hospitals in Israel. Both general and ear, nose and throat surgeons are familiar with thyroidectomy for cervical goiters. In about 1-15% of thyroidectomies, the goiter is intrathoracic and requires somewhat different management. This topic has not been reviewed in the literature recently. OBJECTIVE: To evaluate the clinical presentation, preoperative workup, surgical complications and risk of malignancy in retrosternal goiters. METHODS: We retrospectively reviewed the records of 75 patients who underwent thyroidectomy for retrosternal goiter in the General Thoracic Surgical Department of our institution during a 15 year period, January 1990 to January 2005. RESULTS: All the patients (41 women and 34 men) were symptomatic at presentation, with choking and dyspnea being the most common complaint. Computerized tomography scan of the neck and chest were obtained before the operation in 71 patients (95%). Ten patients (13%) had a previous partial thyroidectomy. A cervical approach was used in 68 patients (91%). Seven patients (9%) required median sternotomy to complete the operation. One patient (1.3%) died from postoperative respiratory failure. Transient recurrent laryngeal nerve palsy occurred in 5 patients (7%) and permanent RLNP in 3 (4%). The incidence of transient and permanent hypoparathyroidism was 10% and 2.6% respectively. Sixty-six lesions (88%) were benign and 9 (12%) were malignant. CONCLUSIONS: Choking and dyspnea are the most common presenting symptoms of retrosternal goiter. CT scan is an important component of the preoperative evaluation and operative planning. Surgical removal of the thyroid is the treatment of choice and most patients have symptomatic improvement following the operation. Since a substernal thyroidectomy may be technically different from cervical thyroidectomy, a surgical team familiar with its unique pitfalls should perform the procedure.

Involvement of Heparanase in Empyema: Implication for Novel Therapeutic Approaches.

Pleural empyema is an inflammatory condition that progresses from acute to chronic, life-threatening, phase. The incidence of empyema has been increasing both in children and adults worldwide in the past decades, mainly in healthy young adults and in older patients. Despite continued advances in the management of this condition, morbidity and mortality have essentially remained static over the past decade. Better understanding of the disease and the development of new therapeutic approaches are thus critically needed. Heparanase is an endoglucuronidase that cleaves heparan sulfate chains of proteoglycans. These macromolecules are most abounded in the sub-endothelial and sub-epithelial basement membranes and their cleavage by heparanase leads to disassembly of the extracellular matrix that becomes more susceptible to extravasation and dissemination of metastatic and immune cells. Here, we provide evidence that heparanase expression and activity are markedly increased in empyema and pleural fluids, associating with disease progression. Similarly, heparanase expression is increased in a mouse model of empyema initiated by intranasal inoculation of S. pneumonia. Applying this model we show that transgenic mice over expressing heparanase are more resistant to the infection and survive longer.

Delivery following colon interposition.

BACKGROUND: Colon interposition carries a significant complication rate due to attenuated arterial blood supply, because the interposed colon segment depends on a single vascular pedicle. CASES: We report for the first time five vaginal deliveries in two women following the operation, illustrating the dilemmas encountered in choosing the delivery method in these patients. CONCLUSION: We suggest that vaginal delivery following colon interposition is feasible. If cesarean section has to be performed, extra care must be exercised not to damage the vascular pedicle, particularly when there is a need for mobilizing or palpating the posterior aspect of the uterus.

Emergency percutaneous tracheostomy in trauma patients: an early experience.

BACKGROUND: In recent years, percutaneous tracheostomy (PCT) has become a routine practice in many hospitals. In the early publications, most authors considered adverse conditions such as short or fat neck or obesity as relative contraindications, whereas cervical injury and emergency were regarded as absolute contraindications. More recently, several reports demonstrated the safety and feasibility of PCT in patients with some of the above contraindications. We, like many others, gradually reduced the contraindications and expanded the indications for PCT. In this paper, we report our early experience with emergency PCT in trauma patients. METHODS: Ten adult patients suffering from multiple injuries after motor vehicle accident (7) or severe head and neck burns (3) required emergency surgical airway control after failure to accomplish orotracheal intubation. A modified Griggs' technique was used by experienced thoracic surgeons. Recorded data included patient demographics, clinical and anatomic conditions, length of procedure, and complications. Short-term follow-up was performed in the hospital by thoracic staff surgeons. Long-term follow-up was carried out in the outpatient clinic. RESULTS: Six male and 4 female patients underwent emergency PCT. The mean time from skin incision to intubation was 5.5 minutes including the oxygen insufflation period. There was no failure, no procedure-related complication, and no conversion to open technique. Five patients survived and underwent uneventful decannulation. In approximately 1 year of follow-up, there were no clinical symptoms or signs of complications related to the tracheostomy. CONCLUSIONS: Emergency PCT using a modified Griggs' technique is feasible and safe. In experienced hands, it might be even easier and faster than the open surgical tracheostomy.

Pulmonary outcome of Alport syndrome with familial diffuse esophageal leiomyomatosis.

X-linked Alport syndrome is associated in some families with diffuse leiomyomatosis. We describe herein, the pulmonary complications and outcome of three family members (mother, daughter, and son). The three underwent esophagectomy at different ages (22 years, three years, and 15 months respectively). Their current forced expiratory volume in the first second (FEV1) ranged from 33% in the mother to 60% in the daughter and 97% in the son. It is suggested that earlier intervention may lead to improved pulmonary function tests.

Thoracic outlet syndrome caused by hydatid cyst of the first rib-rare but important.

Hydatid cysts are usually located in the liver and lungs. Skeletal echinococcosis is relatively rare and that of the rib is exceptional. Less than 50 cases of costal echinococcosis have been reported in the literature so far. To our knowledge, only one case report of thoracic outlet syndrome due to echinococcal cyst in the first rib was described in 1995. Accurate pre-operative diagnosis is important but may be challenging in some cases. Reported here is a case of echinococcosis of the first rib in a young adult who was presented with thoracic outlet syndrome. Plain chest radiograph, CT scan and MRI were performed. The imaging features were suggestive of a solitary aneurysmal bone cyst and the differential diagnosis included echinococcosis of the first rib. The lesion was completely resected and the histopathological examination confirmed the diagnosis of echinococcosis.

Enhanced presurgical pain temporal summation response predicts post-thoracotomy pain intensity during the acute postoperative phase.

UNLABELLED: Recent evidence points to an association between experimental pain measures obtained preoperatively and acute postoperative pain (POP). We hypothesized that pain temporal summation (TS) might be an additional predictor for POP insofar as it represents the neuroplastic changes that occur in the central nervous system following surgery. Therefore, a wide range of psychophysical tests (TS to heat and mechanical repetitive stimuli, pain threshold, and suprathreshold pain estimation) and personality tests (pain catastrophizing and anxiety levels) were administered prior to thoracotomy in 84 patients. POP ratings were evaluated on the 2nd and 5th days after surgery at rest (spontaneous pain) and in response to activity (provoked pain). Linear regression models revealed that among all assessed variables, enhanced TS and higher pain scores for mechanical stimulation were significantly associated with greater provoked POP intensity (overall r2 = 0.225, P = .008). Patients who did not demonstrate TS to both modalities reported lower scores of provoked POP as compared with patients who demonstrated TS in response to at least 1 modality (F = 4.59 P = .013). Despite the moderate association between pain catastrophizing and rest POP, none of the variables predicted the spontaneous POP intensity. These findings suggest that individual susceptibility toward a greater summation response may characterize patients who are potentially vulnerable to augmented POP. PERSPECTIVE: This study proposed the role of pain temporal summation assessed preoperatively as a significant psychophysical predictor for acute postoperative pain intensity. The individual profile of enhanced pain summation is associated with the greater likelihood of higher postoperative pain scores.

A simple method of using a Foley catheter to drain pleural effusion.

Pleural effusion is a common problem, and various techniques of pleural fluid drainage have been described. We report our experience of using a Foley-type catheter to drain pleural effusion. After the injection of local anesthesia, the catheter is inserted, usually through the 7th intercostal space, with the patient sitting upright. The size of the catheter is selected according to the predicted fluid characteristics, and ranges from 18 to 24 F. Once the catheter is positioned in the pleural space, the balloon is inflated with diluted soluble contrast material and connected to a urine collection bag. During the last 10 years, we have used 3500 catheters for this purpose. The catheter site can be used as a port for various procedures, including needle biopsy of the parietal pleura, talc-slurry pleurodesis, and intra-pleural fibrinolysis. This method of pleural drainage is simple, reliable, and inexpensive.

Prediction of chronic post-operative pain: pre-operative DNIC testing identifies patients at risk.

Surgical and medical procedures, mainly those associated with nerve injuries, may lead to chronic persistent pain. Currently, one cannot predict which patients undergoing such procedures are 'at risk' to develop chronic pain. We hypothesized that the endogenous analgesia system is key to determining the pattern of handling noxious events, and therefore testing diffuse noxious inhibitory control (DNIC) will predict susceptibility to develop chronic post-thoracotomy pain (CPTP). Pre-operative psychophysical tests, including DNIC assessment (pain reduction during exposure to another noxious stimulus at remote body area), were conducted in 62 patients, who were followed 29.0+/-16.9 weeks after thoracotomy. Logistic regression revealed that pre-operatively assessed DNIC efficiency and acute post-operative pain intensity were two independent predictors for CPTP. Efficient DNIC predicted lower risk of CPTP, with OR 0.52 (0.33-0.77 95% CI, p=0.0024), i.e., a 10-point numerical pain scale (NPS) reduction halves the chance to develop chronic pain. Higher acute pain intensity indicated OR of 1.80 (1.28-2.77, p=0.0024) predicting nearly a double chance to develop chronic pain for each 10-point increase. The other psychophysical measures, pain thresholds and supra-threshold pain magnitudes, did not predict CPTP. For prediction of acute post-operative pain intensity, DNIC efficiency was not found significant. Effectiveness of the endogenous analgesia system obtained at a pain-free state, therefore, seems to reflect the individual's ability to tackle noxious events, identifying patients 'at risk' to develop post-intervention chronic pain. Applying this diagnostic approach before procedures that might generate pain may allow individually tailored pain prevention and management, which may substantially reduce suffering.

Video-assisted thoracoscopic surgery in the treatment of chest trauma: long-term benefit.

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) has gained an increasing importance as a diagnostic and therapeutic tool in chest trauma. Several studies have demonstrated its feasibility and safety, but only a few addressed the long-term benefit of VATS. The aim of this study was to evaluate the short-term and long-term benefits of VATS in chest trauma, with emphasis on the patient's point of view. METHODS: Medical records of patients with chest trauma during a 10-year period were reviewed. The study included 77 patients (37 patients in the VATS group and 40 in the thoracotomy group). Forty-four patients who underwent operative treatment during the study period were excluded from the study. Hospital charts and a telephone questionnaire were used to evaluate the outcome. RESULTS: No deaths occurred in either group. Clotted hemothorax was the most common finding. The incidence of wound and pulmonary complication were higher in the thoracotomy group. Patients in the thoracotomy group needed significantly higher doses of narcotic analgesia. Average time to resume normal activity was shorter in the VATS group. More than 2 years after discharge, the rate of return to a normal lifestyle was 81% in the VATS group and 60% of the thoracotomy group. Patients in the VATS group were generally more satisfied with their health status and surgical scars. CONCLUSIONS: The results of this study show that for stable patients with chest trauma, video assisted thoracic surgery is feasible and safe. Moreover, it is tolerated better than open thoracotomy, has a favorable postoperative course, a superior long-term outcome, and greater patient satisfaction.

Percutaneous tracheostomy in patients with cervical spine fractures--feasible and safe.

The aim of this study is to evaluate the short and long-term results of percutaneous tracheostomy in patients with documented cervical spine fracture. Between June 2000 and September 2005, 38 consecutive percutaneous tracheostomy procedures were performed on multi-trauma patients with cervical spine fracture. Modified Griggs technique was employed at the bedside in the general intensive care department. Staff thoracic surgeons and anesthesiologists performed all procedures. Demographics, anatomical conditions, presence of co-morbidities and complication rates were recorded. The average operative time was 10 min (6-15). Two patients had minor complications. One patients had minor bleeding (50 cc) and one had mild cellulitis. Nine patients had severe paraparesis or paraplegia prior to the PCT procedure and 29 were without neurological damage. There was no PCT related neurological deterioration. Twenty-eight patients were discharged from the hospital, 21 were decannulated. The average follow-up period was 18 months (1-48). There was no delayed, procedure related, complication. These results demonstrate that percutaneous tracheostomy is feasible and safe in patients with cervical spine fracture with minimal short and long-term morbidity. We believe that percutaneous tracheostomy is the procedure of choice for patients with cervical spine fracture who need prolonged ventilatory support.

Never say no to a damaged muscle: the applications of previously damaged pectoralis major and latissimus dorsi muscles for chest wall reconstruction.

The nondamaged latissimus dorsi and pectoralis major muscles are widely reported in the literature as being the most frequently used for chest wall reconstruction. In this study, we report a series of 9 patients with full-thickness chest wall defects who underwent reconstruction with previously damaged latissimus dorsi or pectoralis major muscles. Nine patients underwent chest wall reconstruction over a period of 3 years using previously damaged latissimus dorsi or pectoralis major muscles. The thoracic defect was posttraumatic in 3 patients and post-tumor resection in 6 patients. Three patients had previous radiation therapy. In 8 cases, the full-thickness chest wall defects were completely closed. The only failure encountered was in one patient who had a long lasting fistula. The proximal based island flap that was inserted into the tract showed good vascular supply and viability; however, it did not solve the clinical problem. Keeping in mind the basic rule of medicine ("Primum Non Nocere") and a thorough knowledge of the surgical anatomy of these muscles are essential for the successful application of these previously damaged muscles for chest wall reconstruction.

Extended indications for percutaneous tracheostomy.

BACKGROUND: In recent years, percutaneous tracheostomy has become a routine practice in many hospitals. In the early publications, most authors considered adverse conditions such as short, fat neck or obesity as relative contraindications whereas cervical injury, coagulopathy, and emergency were regarded as absolute contraindications. More recently, several reports demonstrated the feasibility of percutaneous tracheostomy in patients with some of these contraindications. The aim of this study is to determine the safety and efficacy of percutaneous tracheostomy in conditions commonly referred to as contraindications. METHODS: Between June 2000 and July 2001, 157 consecutive percutaneous tracheostomy procedures were performed on 154 critically ill adult patients in the general intensive care unit of a major tertiary care facility. The Griggs technique and Portex set were used at the bedside. All procedures were performed by staff thoracic surgeons and anesthesiologists experienced with the technique. Anatomical conditions, presence of coagulopathy and anti-coagulation therapy, demographics, and complication rates were recorded. RESULTS: Five of 157 procedures (154 patients owing to three repeat tracheostomies) had complications. In patients with normal anatomical conditions and coagulation profiles, there was one case of bleeding (50 cc to 120 cc) and one case of mild cellulitis around the stoma. In patients with adverse conditions, there was one case of bleeding (50 cc to 120 cc) and two cases of minor bleeding (< 50 cc). CONCLUSIONS: Patients with adverse conditions had a low complication rate similar to patients with normal conditions. For this reason, we believe that percutaneous tracheostomy is indicated in patients with short, fat neck; inability to perform neck extension; enlarged isthmus of thyroid; previous tracheostomy; or coagulopathy and anti-coagulation therapy.