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World Journal of Hepatology May 2017A 59-year-old male with alcoholic cirrhosis presented to our hospital with an acutely painful umbilical hernia, and 4 mo of exertional dyspnea. He was noted to be...
A 59-year-old male with alcoholic cirrhosis presented to our hospital with an acutely painful umbilical hernia, and 4 mo of exertional dyspnea. He was noted to be tachypneic and hypoxic. He had a massive right sided pleural effusion with leftward mediastinal shift and gross ascites, with a tense, fluid-filled, umbilical hernia. Emergent paracentesis with drain placement and a large volume thoracentesis were performed. Despite improvement in dyspnea and drainage of 15 L of ascitic fluid, the massive transudative pleural effusion remained largely unchanged. He underwent a repeat large volume thoracentesis on hospital day 4. The patient subsequently developed a tension pneumothorax, which resulted in a dramatic reduction in the effusion. A chest tube was placed and serial radiographs demonstrated resolution of the pneumothorax but recurrence of the effusion. The radiographs illustrate the movement of fluid between the peritoneal and pleural cavities. In this case, the mechanism of pleural effusion was confirmed to be a hepatic hydrothorax an unintended tension pneumothorax. Methods to elucidate a hepatic hydrothorax include Tc99m or indocyanine green injection into the ascitic fluid followed by its demonstration above the diaphragm. The unintended tension pneumothorax in this case additionally demonstrates bi-directional flow across the diaphragm.
PubMed: 28539992
DOI: 10.4254/wjh.v9.i13.642 -
Multimedia Manual of Cardiothoracic... Jan 2009Postpneumonectomy syndrome is a rare postoperative complication whereby mediastinal shifting toward the pneumonectomy space results in bronchial compression between the...
Postpneumonectomy syndrome is a rare postoperative complication whereby mediastinal shifting toward the pneumonectomy space results in bronchial compression between the pulmonary artery, aorta, and vertebral column. This syndrome is more common after right pneumonectomy; other risk factors include young age and female sex. Imaging studies consistently reveal massive mediastinal shifting and document airway compromise. Bronchoscopy and flow-volume loops are helpful in confirming the diagnosis. Other causes of dyspnea, including cancer recurrence, should be excluded. Definitive treatment involves surgical repositioning of the mediastinum in the midline, as well as insertion of a saline-filled silicone prosthesis into the pneumonectomy space in order to prevent recurrence.
PubMed: 24413710
DOI: 10.1510/mmcts.2008.003475 -
Multimedia Manual of Cardiothoracic... 2015Sternotomy is considered to be the gold standard incision in cardiac surgery, resulting in low failure rates and excellent proven long-term outcomes. It can also be used...
Sternotomy is considered to be the gold standard incision in cardiac surgery, resulting in low failure rates and excellent proven long-term outcomes. It can also be used in thoracic surgery for mediastinal, bilateral pulmonary or lower trachea and main stem bronchus surgery. Sternotomy has to be performed properly to avoid short- and long-term morbidity and mortality. The surgical technique is well established and certain principles are recognized to be crucial to minimize complications. The identification of the correct landmarks, midline tissue preparation, osteotomy with the avoidance of injury to underlying structures like pleura, pericardium, innominate vein, brachiocephalic artery and ectatic ascending aorta, and targeted bleeding control are important steps of the procedure. As important as the performance of a proper sternotomy is a correct sternal closure. An override or shift of the sternal edges has to be avoided by placing the wires at a proper distance from each other without injuring the thoracic pedicle. The two sternal halves have to be tightly re-approximated to facilitate healing of the bone and to avoid instability, which is a risk factor for wound infection. With a proper performance of sternotomy and sternal closure, instability and wound infections are rare and depend on patient-related risk factors.
Topics: Bone Wires; Cardiac Surgical Procedures; Humans; Osteotomy; Sternotomy; Wound Closure Techniques
PubMed: 26188337
DOI: 10.1093/mmcts/mmv017 -
Endoscopic Ultrasound 2020EUS-guided tissue acquisition (EUS-TA) has made rapid development since its introduction in the early 1990s. The technique is widely accepted and invaluable for staging... (Review)
Review
EUS-guided tissue acquisition (EUS-TA) has made rapid development since its introduction in the early 1990s. The technique is widely accepted and invaluable for staging and diagnosis of a variety of upper gastrointestinal and mediastinal lesions. Fine-needle aspiration (FNA) has long been the gold standard, but due to its limitations such as the inability to retain stroma and associated cellular architecture, novel biopsy needles (FNB) were designed. Overall, FNA and FNB needles perform seemingly equally in terms of diagnostic accuracy, however, the second-generation FNB needles require less passes. The third-generation FNB needles (crown-cut needle types) seem to be preferable to FNA needles as well as to the second-generation FNB needles, when larger histological specimens and preserved tissue architecture are required. EUS-TA is constantly under development, and new applications of this technique include tumor risk stratification according to its genetic profile as well as minimally invasive creation of patient-derived organoids, hallmarks of personized medicine. It remains yet to be shown, whether these applications will lead to a decisive shift from aspiration to biopsy, i.e., from A to B.
PubMed: 32655082
DOI: 10.4103/eus.eus_21_20 -
Danish Medical Journal Mar 2017PTA is a collection of pus located between the tonsillar capsule and the pharyngeal constrictor muscle. It is considered a complication of acute tonsillitis and is the... (Review)
Review
PTA is a collection of pus located between the tonsillar capsule and the pharyngeal constrictor muscle. It is considered a complication of acute tonsillitis and is the most prevalent deep neck infection (approximately 2000 cases annually in Denmark) and cause of acute admission to Danish ENT departments. Teenagers and young adults are most commonly affected and males may predominate over females. However, no studies of age- and gender-stratified incidence rates have previously been published. Furthermore, smoking may be associated with increased risk of peritonsillar abscess (PTA) development, although the magnitude of the association has not been estimated. Complications are relatively rare. They include parapharyngeal abscess (PPA), upper airway obstruction, Lemierre´s syndrome, necrotizing fasciitis, mediastinitis, erosion of the internal carotid artery, brain abscess, and streptococcal toxic shock syndrome. The treatment consists of abscess drainage and antimicrobial therapy. There are three accepted methods of surgical intervension: needle aspiration, incision and drainage (ID), and acute tonsillectomy (á chaud). Internationally, there is a strong trend towards less invasive surgical approach to PTA treatment with avoidance of acute tonsillectomy, needle aspiration instead of ID, and in some cases even antibiotic treatment without surgical drainage. The preferred antibiotic regimen varies greatly between countries and centers. Group A streptococcus (GAS) is the only established pathogen in PTA. However, GAS is only recovered from approximately 20% of PTA patients. The pathogens in the remaining 80% are unknown. Culturing of PTA pus aspirates often yields a polymicrobial mixture of aerobes and anaerobes. As the tonsils of healthy individuals are already heavily and diversely colonized, the identification of significant pathogens is challenging. In addition, when studying PTA microbiology, one must consider diagnostic precision, collection, handling, and transportation of appropriate specimens, choice of methodology for detection and quantification of microorganisms, current or recent antibiotic treatment of patients, potential shift in significant pathogens during the course of infection, and factors associated with increased risk of PTA development. The trend towards de-escalated surgical intervention and increasing reliance on antibiotic treatment, require studies defining the significant pathogens in PTA in order to determine optimal antibiotic regimens. Complications secondary to PTA may be avoided or better controlled with improved knowledge concerning the significant pathogens in PTA. Furthermore, identification of pathogens other than GAS, may lead the way for earlier bacterial diagnosis and timely intervention before abscess formation in sore throat patients. The identification and quantification of risk factors for PTA development constitutes another approach to reduce the incidence of PTA. As clinicians, we noticed that FN was recovered from PTA patients with increasing frequency and that patients infected with Fusobacterium necrophorum (FN) seemed to be more severely affected than patients infected with other bacteria. Furthermore, we occationally observed concomitant PPA in addition to a PTA, which made us hypothesize that PPA and PTA is often closely related and may share significant pathogens. Hence, our aims were: 1. To explore the microbiology of PTA with a special attention to Fusobacterium necrophorum (FN). 2. To elucidate whether smoking, age, gender, and seasons are risk factors for the development of PTA. 3. To characterize patients with PPA, explore the relationship between PPA and PTA, identify the pathogens associated with PPA, and review our management of PPA. In a retrospective study on all 847 PTA patients admitted to the ENT department at Aarhus University Hospital (AUH) from 2001 to 2006, we found that FN was the most prevalent (23%) bacterial strain in pus specimens. FN-positive patients displayed significantly higher infection markers (CRP and neutrophil counts) than patients infected with other bacteria (P = 0.01 and P < 0.001, respectively). In a subsequent prospective and comparative study on 36 PTA patients and 80 patients undergoing elective tonsillectomy (controls), we recovered FN from 58% of PTA aspirates. Furthermore, FN was detected significantly more frequently in the tonsillar cores of PTA patients (56%) compared to the tonsillar cores of the controls (24%) (P = 0.001). We also analysed sera taken acutely and at least two weeks after surgery for the presence of anti-FN antibodies. We found increasing levels (at least two-fold) of anti-FN antibodies in eight of 11 FN-positive (in the tonsillar cultures) PTA patients, which was significantly more frequent compared to none of four FN-negative PTA patients and nine of 47 electively tonsillectomized controls (P = 0.026 and P < 0.001, respectively). Blood cultures obtained during acute tonsillectomy mirrored the bacterial findings in the tonsillar specimens with 22% of patients having bacteremia with FN. However, bacteremia during elective tonsillectomy was at least as prevalent as bacteremia during quinsy tonsillectomy, which challenges the distinction made by the European Society of Cardiology between quinsy and elective tonsillectomy, namely that antibiotic prophylaxis is only recommended to patients undergoing procedures to treat an established infection (i.e. PTA). Using PCR analysis for the presence of herpes simplex 1 and 2, adenovirus, influenza A and B, Epstein-Barr virus (EBV), and respiratory syncytial virus A and B, we explored a possible role of viruses in PTA. However, our results did not indicate that any of these viruses are involved in the development of PTA. Privious studies have documented an association between EBV and PTA in approximately 4% of PTA cases. In addition to the involvement of GAS, the following findings suggest a pathogenic role for FN in PTA: 1. Repeated high isolation rates of FN in PTA pus aspirates. 2. Higher isolation rates in PTA patients compared to electively tonsillectomised controls. 3. Development of anti-FN antibodies in FN-positive patients with PTA. 4. Significantly higher inflammatory markers in FN-positive patients compared to PTA patients infected with other bacteria. We studied the smoking habits among the same 847 PTA patients admitted to the ENT department, AUH from 2001 to 2006. We found that smoking was associated with increased risk of PTA for both genders and across all age groups. The increased risk of PTA among smokers was not related to specific bacteria. Conclusions on causality cannot be drawn from this retrospective study, but the pathophysiology behind the increased risk of PTA in smokers may be related to, previously shown, alterations in the tonsillar, bacterial flora or the local and systemical inflammatory and immunological milieu. Studying all 1,620 patients with PTA in Aarhus County from 2001 to 2006 and using population data for Aarhus County for the same six years, age- and gender-stratified mean annual incidence rates of PTA were calculated. The incidence of PTA was highly related to age and gender. The seasonal variation of PTA was insignificant. However, the microbiology of PTA fluctuated with seasons: GAS-positive PTA cases were significantly more prevalent in the winter and spring compared to the summer, while FN-positive PTA patients exhibited a more even distribution over the year, but with a trend towards higher prevalence in the summer than in the winter. In a series of 63 patients with PPA, we found that 33 (52%) patients had concomitant PTA. This association between PPA and PTA was much higher than previously documented. We therefore suggest that combined tonsillectomy and intrapharyngeal incision in cases where PTA is present or suspected. The results of our routine cultures could not support a frequent role of FN in PPA. Based on our findings suggesting that FN is a frequent pathogen in PTA, we recommend clindamycin instead of a macrolide in penicillin-allergic patients with PTA. Furthermore, cultures made from PTA aspirates should include a selective FN-agar plate in order to identify growth of this bacterium. Recent studies of sore throat patients document an association between recovery of FN and acute tonsillitis. Studying the bacterial flora of both tonsils in study II, we found almost perfect concordance between the bacterial findings of the tonsillar core at the side of the abscess and contralaterally. This finding suggests that FN is not a subsequent overgrowth phenomenon after abscess development, but that FN can act as pathogen in severe acute tonsillitis. Future studies of patients with FN-positive acute tonsillitis focusing on the optimal methods (clinical characteristics, culture, polymerase chain reaction, or other) for diagnosis and whether antibiotics (and which) can reduce symptoms and avoid complications are warranted. Until further studies are undertaken, we recommend clinicians to have increased focus on acute tonsillitis patients aged 15-24 years with regards to symptoms and findings suggestive of incipient peritonsillar involvement. We have conducted a number of studies with novel findings: 1. FN is a significant and prevalent pathogen in PTA. 2. Bacteremia during abscess tonsillectomy is no more prevalent than during elective tonsillectomy. 3. The development of anti-FN antibodies in FN-positive PTA patients. We have used novel approaches as principles to suggest pathogenic significance of candidate microorganisms: 1. Comparative microbiology between PTA patients and "normal tonsils". 2. Measurements indicating larger inflammatory response compared to clinically equivalent infection.
Topics: Abscess; Adolescent; Adult; Age Factors; Child; Female; Fusobacterium Infections; Fusobacterium necrophorum; Humans; Male; Middle Aged; Palatine Tonsil; Peritonsillar Abscess; Pharyngeal Diseases; Risk Factors; Seasons; Sex Factors; Smoking; Streptococcal Infections; Streptococcus pyogenes; Young Adult
PubMed: 28260599
DOI: No ID Found -
Turk Gogus Kalp Damar Cerrahisi Dergisi Jan 2024Pneumothorax is a condition that describes the presence of air between the visceral and parietal pleura sheets and the consequent collapse of the lungs. The collapse of... (Review)
Review
Pneumothorax is a condition that describes the presence of air between the visceral and parietal pleura sheets and the consequent collapse of the lungs. The collapse of the lungs can be partial or total and can present in different clinical stages, such as a high-pressure pneumothorax that can cause a mediastinal shift. Pneumomediastinum is the presence of free air between the mediastinal tissues due to various causes. It can manifest spontaneously and be minimally symptomatic but can also develop due to severe complications. Its etiology includes numerous iatrogenic and traumatic factors. Although spontaneous pneumothorax and pneumomediastinum that develop in childhood are similar to adult patients, it is important to determine the appropriate treatment strategy in addition to the age group, the effectiveness of the treatment, the role of the applied treatment in reducing recurrence, and the etiologyoriented treatments if there is an underlying pathology.
PubMed: 38584791
DOI: 10.5606/tgkdc.dergisi.2024.25755 -
Diagnostic and Interventional Imaging Oct 2016The major lung resections are the pneumonectomies and lobectomies. The sublobar resections are segmentectomies and wedge resections. These are performed either through... (Review)
Review
The major lung resections are the pneumonectomies and lobectomies. The sublobar resections are segmentectomies and wedge resections. These are performed either through open surgery through a thoracotomy or by video-assisted mini-invasive surgery for lobectomies and sublobar resections. Understanding the procedures involved allows the normal postoperative appearances to be interpreted and these normal anatomical changes to be distinguished from potential postoperative complications. Surgery results in a more or less extensive physiological adaptation of the chest cavity depending on the lung volume, which has been resected. This adaptation evolves during the initial months postoperatively. Chest radiography and computed tomography can show narrowing of the intercostal spaces, a rise of the diaphragm and shift of the mediastinum on the side concerned following major resections.
Topics: Adenocarcinoma; Adult; Aged; Female; Follow-Up Studies; Humans; Lung; Lung Neoplasms; Male; Middle Aged; Pneumonectomy; Postoperative Complications; Solitary Pulmonary Nodule; Surgery, Computer-Assisted; Surgical Instruments; Thoracic Surgery, Video-Assisted; Thoracostomy; Thoracotomy; Tomography, X-Ray Computed
PubMed: 27687830
DOI: 10.1016/j.diii.2016.08.014 -
The Canadian Journal of Infectious... Mar 2001The objective of the present paper is to describe the clinical and computed tomography features of 'explosive pleuritis', an entity first named by Braman and Donat in...
The objective of the present paper is to describe the clinical and computed tomography features of 'explosive pleuritis', an entity first named by Braman and Donat in 1986, and to propose a case definition. A case report of a previously healthy, 45-year-old man admitted to hospital with acute onset pleuritic chest pain is presented. The patient arrived at the emergency room at 15:00 in mild respiratory distress; the initial chest x-ray revealed a small right lower lobe effusion. The subsequent clinical course in hospital was dramatic. Within 18 h of admission, he developed severe respiratory distress with oxygen desaturation to 83% on room air and dullness of the right lung field. A repeat chest x-ray, taken the morning after admission, revealed complete opacification of the right hemithorax. A computed tomography scan of the thorax demonstrated a massive pleural effusion with compression of pulmonary tissue and mediastinal shift. Pleural fluid biochemical analysis revealed the following concentrations: glucose 3.5 mmol/L, lactate dehydrogenase 1550 U/L, protein 56.98 g/L, amylase 68 U/L and white blood cell count 600 cells/mL. The pleural fluid cultures demonstrated light growth of coagulase-negative staphylococcus and viridans streptococcus, and very light growth of Candida albicans. Cytology was negative for malignant cells. Thoracotomy was performed, which demonstrated a loculated parapneumonic effusion that required decortication. The patient responded favourably to the empirical administration of intravenous levofloxacin and ceftriaxone, and conservative surgical methods in the management of the empyema. This report also discusses the patient's rapidly progressing pleural effusion and offers a potential case definition for explosive pleuritis. Explosive pleuritis is a medical emergency defined by the rapid development of a pleural effusion involving more than 90% of the hemithorax over 24 h, which causes compression of pulmonary tissue and mediastinal shift to the contralateral side.
PubMed: 18159325
DOI: 10.1155/2001/656097