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The Cochrane Database of Systematic... Oct 2007The nature and indications for thyroid surgery vary and a perceived risk of haemorrhage post-surgery is one reason why wound drains are frequently inserted. However when... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The nature and indications for thyroid surgery vary and a perceived risk of haemorrhage post-surgery is one reason why wound drains are frequently inserted. However when a significant bleed occurs, wound drains may become blocked and the drain does not obviate the need for surgery or meticulous haemostasis. The evidence in support of the use of drains post-thyroid surgery is unclear therefore and a systematic review of the best available evidence was undertaken.
OBJECTIVES
To determine the effects of inserting a wound drain during thyroid surgery, on wound complications, respiratory complications and mortality.
SEARCH STRATEGY
We searched the following databases: Cochrane Wounds Group Specialised Register and the Cochrane Central Register of Controlled Trials (CENTRAL) (issue 1, 2007); MEDLINE (2005 to February 2007); EMBASE (2005 to February 2007); CINAHL (2005 to February 2007) using relevant search strategies.
SELECTION CRITERIA
Only randomised controlled trials were eligible for inclusion. Quasi randomised studies were excluded. Studies with participants undergoing any form of thyroid surgery, irrespective of indications, were eligible for inclusion in this review. Studies involving people undergoing parathyroid surgery and lateral neck dissections were excluded. At least 80% follow up (till discharge) was considered essential.
DATA COLLECTION AND ANALYSIS
Studies were assessed for eligibility and data were extracted by two authors independently, differences were resolved by discussion. Studies were assessed for validity including criteria on whether they used a robust method of random sequence generation and allocation concealment. Missing and unclear data were resolved by contacting the study authors.
MAIN RESULTS
13 eligible studies were identified (1646 participants). 11 studies compared drainage with no drainage and found no significant difference in re-operation rates; incidence of respiratory distress and wound infections. Post-operative wound collections needing aspiration or drainage were significantly reduced by drains (RR 0.51, 95% CI 0.27 to 0.97), but a further analysis of the 4 high quality studies showed no significant difference (RR 1.82, 95% CI 0.51 to 6.46). Hospital stay was significantly prolonged in the drain group (WMD 1.18 days, 95% CI 0.73 to 1.63).Eleven studies compared suction drain with no drainage and found no significant difference in re-operation rates; incidence of respiratory distress and wound infection rates. The incidence of collections that required aspiration or drainage without formal re-operation was significantly less in the drained group (RR 0.48, 95% CI 0.25 to 0.92). However, further analysis of only high quality studies showed no significant difference (RR 1.78, 95% CI 0.44 to 7.17). Hospital stay was significantly prolonged in the drain group (WMD 1.20 days, 95% CI 0.77 to 1.63). One study compared open drain with no drain. No participant in either group required re-operation. No data were available regarding the incidence of respiratory distress, wound infection and pain. The incidence of collections needing aspiration or drainage without re-operation was not significantly different between the groups and there was no significant difference in length of hospital stay. One study compared suction drainage with passive closed drainage. None of the participants in the study needed re-operation and data regarding other outcomes were not available. Two studies (180 participants) compared open drainage with suction drainage. One study reported wound infections and minor wound collections, both were not significantly different. The other study reported wound collections requiring intervention and hospital stay; both were not significantly different. None of the participants in either study required re-operation. Data regarding other outcomes were not available.
AUTHORS' CONCLUSIONS
There is no clear evidence that using drains in patients undergoing thyroid operations significantly improves patient outcomes and drains may be associated with an increased length of hospital stay. The existing evidence is from trials involving patients having goitres without mediastinal extension, normal coagulation indices and the operation not involving any lateral neck dissection for lymphadenectomy.
Topics: Drainage; Hematoma; Humans; Length of Stay; Pain, Postoperative; Postoperative Hemorrhage; Randomized Controlled Trials as Topic; Respiratory Distress Syndrome; Seroma; Surgical Wound Infection; Thyroid Diseases; Thyroidectomy
PubMed: 17943885
DOI: 10.1002/14651858.CD006099.pub2 -
Journal of Immunology (Baltimore, Md. :... Feb 2021Although fibrotic disorders are frequently assumed to be linked to T cells, quantitative tissue interrogation studies have rarely been performed to establish this link...
Although fibrotic disorders are frequently assumed to be linked to T cells, quantitative tissue interrogation studies have rarely been performed to establish this link and certainly many fibrotic diseases do not fall within the type 2/allergic disease spectrum. We have previously linked two human autoimmune fibrotic diseases, IgG4-related disease and systemic sclerosis, to the clonal expansion and lesional accumulation of CD4CTLs. In both these diseases T cell accumulation was found to be sparse. Fibrosing mediastinitis linked to infection histologically resembles IgG4-related disease in terms of the inflammatory infiltrate and fibrosis, and it provides an example of a fibrotic disease of infectious origin in which the potentially profibrotic T cells may be induced and reactivated by fungal Ags. We show in this study that, in this human disease, CD4CTLs accumulate in the blood, are clonally expanded, infiltrate into disease lesions, and can be reactivated in vitro by Ags. T cells are relatively sparse at lesional sites. These studies support a general role for CD4CTLs in inflammatory fibrosis and suggest that fibrosing mediastinitis is an Ag-driven disease that may provide important mechanistic insights into the pathogenesis of idiopathic fibrotic diseases.
Topics: Adult; CD4 Antigens; Cells, Cultured; Cohort Studies; Female; Histoplasma; Histoplasmosis; Humans; Immunoglobulin G4-Related Disease; Lymphocyte Activation; Male; Mediastinitis; Middle Aged; Sclerosis; T-Lymphocytes, Cytotoxic; Th2 Cells
PubMed: 33328214
DOI: 10.4049/jimmunol.2000433 -
Ginekologia Polska 2020Fetal cardiac assessment is an integral part of the obstetric ultrasound. The inclusion of the outflow tracts and the three-vessel and tracheal view into the ultrasound... (Review)
Review
Fetal cardiac assessment is an integral part of the obstetric ultrasound. The inclusion of the outflow tracts and the three-vessel and tracheal view into the ultrasound screening enhances the detection rate for cardiovascular anomalies. Both, international and Polish guidelines recommend routine evaluation of the upper mediastinum. The aim of the study was to present the principles for assessing the structures of the upper mediastinum in normal conditions and to draw attention to the pathologies which may be visible in this plane.
Topics: Female; Fetal Heart; Heart Defects, Congenital; Humans; Mediastinum; Pregnancy; Retrospective Studies; Ultrasonography, Prenatal
PubMed: 33184831
DOI: 10.5603/GP.a2020.0092 -
Medicine May 2021Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is less commonly used in nonmalignant diseases. In particular, its application in...
INTRODUCTION
Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is less commonly used in nonmalignant diseases. In particular, its application in mediastinal cystic lesions has been reported less frequently. EBUS-TBNA is a reassuringly safe procedure with an overall complication rate less than 2%, and serious adverse event rate of 0.14% to 0.16%. The most common complications are infections (mediastinal cyst infection most seen).
PATIENT CONCERNS
A 28-year-old male presented to the hospital with mediastinal cyst that was incidentally discovered by computed tomography. There was no past history of the patient reviewed.
DIAGNOSIS
The cyst was identified as a round, anechoic structure by EBUS and serous fluid was aspirated. The carcino-embryonic antigen, mycobacterium tuberculosis DNA and cultures in the fluid were negative. Cytology analysis showed lots of lymphocytes and no malignant cells. The diagnosis of lymphangioma was confirmed based on the computed tomography and EBUS presentation, the nature of the aspirated fluid and the large number of mature lymphocytes within the cystic fluid.
INTERVENTIONS
Twenty-six hours after EBUS-TBNA, the patient complained of a fever with the highest temperature of 39°C, accompanied by a right-side chest pain, no other symptoms of were reported. The following examinations confirmed the diagnosis of pneumonia, pleurisy, mediastinitis and mediastinal cyst infection, while cultures from cyst and right pleural effusion were both negative. The patient was treated with Teicoplanin+Imipenem/cilastatin, and ultrasound guided transcutaneous catheterization drainage of mediastinal cyst and pleural effusion were performed.
OUTCOMES
Seven days after the treatments, the patient's symptoms resolved, the complete blood count, C-reactive protein, erythrocyte sedimentation rate were lowered. The size of the cyst was slightly reduced on 17 June compared to that before EBUS-TBNA. Although the surgical resection of the cyst was recommended, the patient declined. After extracted the two drainage tubes, the patient was discharged on June 22. The patient was followed up by telephone 6 months after discharge and he remained asymptomatic.
CONCLUSIONS
EBUS-TBNA is a useful diagnostic and therapeutic tool for the management of mediastinal cysts. However, considering the possibility of serious complications, the clinical procedure should be carried out scrupulously with appropriate patient selection and strict aseptic principles.
Topics: Adult; Anti-Bacterial Agents; Bronchoscopy; Combined Modality Therapy; Drainage; Drug Therapy, Combination; Endosonography; Humans; Incidental Findings; Male; Mediastinal Cyst; Mediastinitis; Pleurisy; Pneumonia; Surgical Wound Infection; Tomography, X-Ray Computed; Treatment Outcome
PubMed: 34011084
DOI: 10.1097/MD.0000000000025973 -
The American Journal of Case Reports Jan 2021BACKGROUND Fibrosing mediastinitis is a rarely seen, progressive disease. It results from an excessive fibrotic reaction in the mediastinum. We describe a presentation...
BACKGROUND Fibrosing mediastinitis is a rarely seen, progressive disease. It results from an excessive fibrotic reaction in the mediastinum. We describe a presentation of fibrosing mediastinitis that, to our knowledge, has never been seen before. CASE REPORT A 30-year-old female Colombian flight attendant presented with a right eyelid droop. Examination revealed partial right-sided ptosis and miosis but no anhidrosis. An ill-defined firm swelling was palpable at the root of the neck. Chest radiography revealed a widened mediastinum, and computerized tomography (CT) showed a right paratracheal mass without calcification extending to the thoracic inlet, encasing multiple blood vessels. All basic blood tests, magnetic resonance imaging of the head, and ultrasound Doppler of the neck vessels were normal. History and work up for infections including fungal diseases, granulomatous diseases, vasculitis, and autoimmune diseases were negative. Positron emission tomography (PET) showed significant FDG uptake in the mediastinum. Mediastinal biopsy was histologically consistent with fibrosing mediastinitis. All relevant immunohistochemistry and microbiological studies were negative. Subsequently, the patient developed signs of superior vena cava compression; this was managed by balloon angioplasty, which resulted in improvement of symptoms. However, over time, her symptoms worsened progressively, resulting in a left-sided ptosis and radiological progression of the mass on CT. She received treatment with rituximab and concomitant steroids, which yielded excellent results: the treatment led to both resolution of her symptoms and regression of the mass and its metabolic activity on PET scan. CONCLUSIONS Fibrosing mediastinitis can present with an incomplete Horner's syndrome. Treatment with rituximab and steroids shows promising results in select cases of metabolically active idiopathic fibrosing mediastinitis.
Topics: Adult; Blepharoptosis; Female; Humans; Mediastinitis; Miosis; Sclerosis
PubMed: 33431787
DOI: 10.12659/AJCR.927556 -
Medicine Jul 2020Vascular complications of transradial percutaneous coronary intervention (PCI) are rare and usually occur at the access site below the elbow. However, vessels along the...
RATIONALE
Vascular complications of transradial percutaneous coronary intervention (PCI) are rare and usually occur at the access site below the elbow. However, vessels along the tract of the wire or catheter can be injured at any point, causing various types of bleeding complications.
PATIENT CONCERNS
A 57-year-old man visited due to chest discomfort. Coronary angiography showed significant stenosis at the distal right coronary artery (RCA). Immediately after the coronary guidewire was passed through the distal RCA, he started a vigorous cough. The voice changed, dyspnea occurred within minutes, and lip cyanosis and stridor were observed. After endotracheal intubation, successful stenting of the distal RCA was achieved. He was extubated at 30 minutes after coronary stenting, but 1-hour post-extubation, his blood pressure suddenly decreased to 70/50 mmHg.
DIAGNOSIS
Mediastinal widening was newly noted on chest X-ray, and blood hemoglobin was decreased. Contrast-enhanced chest computed tomography showed mediastinal hematoma, tracheal compression, and hemothorax. Contrast extravasation was noted in the terminal branches of the inferior thyroid artery on brachiocephalic angiography.
INTERVENTIONS
Successful hemostasis was achieved with endovascular embolization therapy using a Tornado embolization microcoil, Gelfoam gelatin sponge, and Histoacryl glue. The next day, the mediastinal hemorrhage was drained by mediastinoscopy. The endotracheal intubation and ventilator care were maintained for 2 days, and 6 units of packed red blood cells were transfused. Antithrombotics were used to prevent stent thrombosis, and antibiotics to control infection, respectively.
OUTCOMES
After successful hemostasis, thrombocytosis and high on-treatment platelet reactivity that disappeared at 2 weeks post-discharge were noted. Follow-up chest imaging showed the normalized mediastinal widening. At 14 months post-discharge, the patient remains healthy.
LESSONS
As life-threating vascular complications, such as brachiocephalic, subclavian vessel dissection, and vessel perforation in the internal mammary, costocervical, and thyrocervical arteries, can occur anytime during transradial PCI, the intervention cardiologist should be well aware of it and have the appropriate countermeasures implemented in the routine procedure.
Topics: Blood Loss, Surgical; Coronary Stenosis; Hematoma; Hemostasis, Surgical; Hemothorax; Humans; Male; Mediastinal Diseases; Mediastinum; Middle Aged; Percutaneous Coronary Intervention; Tracheal Diseases
PubMed: 32664170
DOI: 10.1097/MD.0000000000021205 -
Thoracic Cancer May 2023Here, we report a case of mediastinal mesenchymal tumor with a pericytic neoplasm feature that responded to radiation therapy. A 43-year-old man visited our hospital... (Review)
Review
Here, we report a case of mediastinal mesenchymal tumor with a pericytic neoplasm feature that responded to radiation therapy. A 43-year-old man visited our hospital with a complaint of esophageal obstruction and chest pain. Chest computed tomography revealed a middle mediastinal tumor and a mesenchymal tumor was diagnosed with a pericytic neoplasm feature by video-assisted thoracoscopic biopsy. The definitive treatment for soft tissue tumor is surgical resection; however, the mediastinal tumor was unresectable because of esophageal and tracheal invasion. Radiation therapy was administered and there was a partial tumor response and 2 years disease-free status. With a review of the literature, we discuss the clinical and pathological characteristics of this rare tumor and its treatment.
Topics: Male; Humans; Adult; Mediastinal Neoplasms; Mediastinum; Thoracoscopy; Biopsy; Trachea
PubMed: 36965153
DOI: 10.1111/1759-7714.14855 -
Journal of Cardiothoracic Surgery May 2021Systematic lymph node dissection is an important part of radical resection for lung cancer. Insufficient incision of the mediastinal pleura results in a tapered or...
BACKGROUND
Systematic lymph node dissection is an important part of radical resection for lung cancer. Insufficient incision of the mediastinal pleura results in a tapered or tunnel-like operation surface, which increases the difficulty of uniportal video-assisted thoracoscopic mediastinal lymph node dissection. The objective of this study was to report our concept of broad exposure and investigate the efficacy and safety of this concept in uniportal video-assisted thoracoscopic mediastinal lymph nodes dissection.
METHODS
We retrospectively analyzed the clinical data of the 204 non-small cell lung cancer patients who underwent uniportal video-assisted thoracoscopic surgery for anatomical lobectomy and systematic lymph node dissection following the concept of broad exposure. SPSS 23.0 software was used for statistical analysis.
RESULTS
All operations were completed under uniportal video-assisted thoracoscopic surgery following the concept of broad exposure. The median surgery time was 102 (range, 76-285) minutes and the median blood loss was 50 (range, 20-900) milliliters. The median chest tube duration time was 2 (range, 1-6) days, the median postoperative hospital duration time was 5 (range, 4-10) days. The median number of dissected lymph node stations and dissected lymph nodes were 8 (range,6-9) and 15(range,12-19), respectively. The median number of dissected mediastinal lymph nodes stations and dissected mediastinal lymph nodes were 5(range,3-6) and 11(range,10-15), respectively. The up-staging rate of N staging was 6.86%. The postoperative complication rate was 10.29% and there was no perioperative death.
CONCLUSIONS
According to our results, it's effective and safe to perform uniportal video-assisted thoracoscopic mediastinal lymph nodes dissection following the concept of broad exposure. This new concept not only emphasizes sufficient exposure, but also focuses on protection of important tissues.
Topics: Adult; Aged; Blood Loss, Surgical; Carcinoma, Non-Small-Cell Lung; Chest Tubes; Female; Humans; Length of Stay; Lung Neoplasms; Lymph Node Excision; Lymph Nodes; Lymphatic Metastasis; Male; Mediastinum; Middle Aged; Neoplasm Staging; Operative Time; Pneumonectomy; Postoperative Complications; Retrospective Studies; Thoracic Surgery, Video-Assisted
PubMed: 34020671
DOI: 10.1186/s13019-021-01519-6 -
BMC Medical Imaging May 2021Pericardial hematoma is blood accumulation in the pericardial space. Although rare, it could arise in various conditions, such as after cardiac surgery. Clinical... (Review)
Review
BACKGROUND
Pericardial hematoma is blood accumulation in the pericardial space. Although rare, it could arise in various conditions, such as after cardiac surgery. Clinical diagnosis of pericardial hematoma is implausible; thus, cardiac imaging plays a pivotal role in identifying this condition. We presented a case of multiple pericardial hematomas, which was found as an incidental finding in post-cardiac surgery evaluation. We highlighted the diagnostic challenge and the key features of multi-modality cardiac imaging in pericardial hematoma evaluation.
CASE PRESENTATION
An asymptomatic, 35-years old male, who underwent surgical closure of secundum atrial septal defect (ASD) one month ago, came for routine transthoracic echocardiography evaluation. An intrapericardiac hematoma was visualized at the right ventricle (RV) 's free wall side. Another mass with an indistinct border was visualized near the right atrium (RA). This mass was suspected as pericardial hematoma differential diagnosed with intracardiac thrombus. Cardiac computed tomography (CT) scan showed both masses have an attenuation of 30-40 HU; however, the mass's border at the RA side was still not clearly delineated. Mild superior vena cava (SVC) compression and multiple mediastinal lymphadenopathies were also detected. These findings are not typical for pericardial hematomas nor intracardiac thrombus; hence another additional differential diagnosis of pericardial neoplasm was considered. We pursued further cardiac imaging modalities because the patient refused to undergo an open biopsy. Single-photon emission computer tomography (SPECT)/CT with Technetium-99 m (Tc-99 m) macro-aggregated albumin (MAA) and Sestamibi showed filling defect without increased radioactivity, thus exclude the intracardiac thrombus. Cardiac magnetic resonance imaging (MRI) reveals intrapericardial masses with low intensity of T1 signal and heterogeneously high intensity on T2 signal weighted imaged and no evidence of gadolinium enhancement, which concluded the diagnosis as subacute pericardial hematomas. During follow-up, the patient remains asymptomatic, and after six months, the pericardial hematomas were resolved.
CONCLUSION
Pericardial hematoma should be considered as a cause of pericardial masses after cardiac surgery. When imaging findings are atypical, further multi-modality cardiac imaging must be pursued to establish the diagnosis. Careful and meticulous follow-up should be considered for an asymptomatic patient with stable hemodynamic.
Topics: Adult; Diagnosis, Differential; Heart Atria; Heart Neoplasms; Heart Septal Defects, Atrial; Heart Ventricles; Hematoma; Humans; Incidental Findings; Magnetic Resonance Imaging; Male; Multimodal Imaging; Pericardium; Postoperative Complications; Single Photon Emission Computed Tomography Computed Tomography; Thrombosis; Tomography, X-Ray Computed
PubMed: 34006236
DOI: 10.1186/s12880-021-00617-0 -
Journal of Medical Case Reports May 2015A rare complication of chronic pancreatitis is the formation of single or multiple mediastinal pseudocysts, which are fueled from the pancreas through anatomical... (Review)
Review
INTRODUCTION
A rare complication of chronic pancreatitis is the formation of single or multiple mediastinal pseudocysts, which are fueled from the pancreas through anatomical openings of the diaphragm. We present a rare case with a difficult diagnosis, treatment and potentially catastrophic complications.
CASE PRESENTATION
A 53-year-old Caucasian man was referred to our hospital for further investigation and treatment of a large heterogeneous mass situated in the posterior mediastinum, and bilateral pleural effusions which had developed after recent multiple episodes of pancreatitis. He had a history of chronic alcoholism. Laboratory and imaging modalities established the diagnosis of a pancreatic mediastinal pseudocyst.
CONCLUSIONS
Despite successful initial conservative treatment, our patient had a relapse and underwent emergency surgical intervention due to internal hemorrhage. We present his diagnostic and imaging workup, along with the multidisciplinary intervention, and a literature review referring to the diagnosis and treatment of mediastinal pancreatic pseudocysts.
Topics: Diagnosis, Differential; Humans; Male; Mediastinal Diseases; Mediastinum; Middle Aged; Pancreas; Pancreatic Pseudocyst; Pancreatitis, Chronic; Pleural Effusion; Tomography, X-Ray Computed
PubMed: 25962880
DOI: 10.1186/s13256-015-0582-z