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Ceppa DP, Rosati CM, Chabtini L, Stokes SM, Cook HC, Rieger KM, Birdas TJ, Lappas JC, Kessler WR, DeWitt JM, Maglinte DD, Kesler KA. Development of a Multidisciplinary Program to Expedite Care of Esophageal Emergencies. Ann Thorac Surg 2017; 104:1054-1061. [PMID: 28619542 DOI: 10.1016/j.athoracsur.2017.03.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Accepted: 03/13/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Level 1 programs have improved outcomes by expediting the multidisciplinary care of critically ill patients. We established a novel level 1 program for the management of esophageal emergencies. METHODS After institutional review board approval, we performed a retrospective analysis of patients referred to our level 1 esophageal emergency program from April 2013 through November 2015. A historical comparison group of patients treated for the same diagnosis in the previous 2 years was used. RESULTS Eighty patients were referred and transported an average distance of 56 miles (range, 1-163 miles). Median time from referral to arrival was 2.4 hours (range, 0.4-12.9 hours). Referrals included 6 (7%) patients with esophageal obstruction and 71 (89%) patients with suspected esophageal perforation. Of the patients with suspected esophageal perforation, causes included iatrogenic (n = 26), Boerhaave's syndrome (n = 32), and other (n = 13). Forty-six percent (n = 33) of patients were referred because of pneumomediastinum, but perforation could not be subsequently demonstrated. Initial management of patients with documented esophageal perforation included operative treatment (n = 25), endoscopic intervention (n = 8), and supportive care (n = 5). Retrospective analysis demonstrated a statistically significant difference in mean Pittsburgh severity index score (PSS) between esophageal perforation treatment groups (p < 0.01). In patients with confirmed perforations, there were 3 (8%) mortalities within 30 days. More patients in the esophageal level 1 program were transferred to our institution in less than 24 hours after diagnosis than in the historical comparison group (p < 0.01). CONCLUSIONS Development of an esophageal emergency referral program has facilitated multidisciplinary care at a high-volume institution, and early outcomes appear favorable.
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Affiliation(s)
- DuyKhanh P Ceppa
- Division of Cardiothoracic Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana.
| | - Carlo Maria Rosati
- Division of Cardiothoracic Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Lola Chabtini
- Division of Cardiothoracic Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Samantha M Stokes
- Center for Outcomes Research in Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Holly C Cook
- Indiana University Health, Indianapolis, Indiana
| | - Karen M Rieger
- Division of Cardiothoracic Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Thomas J Birdas
- Division of Cardiothoracic Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - John C Lappas
- Department of Radiology, Indiana University School of Medicine, Indianapolis, Indiana
| | - William R Kessler
- Division of Gastroenterology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - John M DeWitt
- Division of Gastroenterology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Dean D Maglinte
- Department of Radiology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Kenneth A Kesler
- Division of Cardiothoracic Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
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Sandstrom CK, Osman SF, Linnau KF. Scary gas: a spectrum of soft tissue gas encountered in the axial body (part II). Emerg Radiol 2017; 24:401-409. [PMID: 28255930 DOI: 10.1007/s10140-017-1491-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 02/14/2017] [Indexed: 11/26/2022]
Abstract
Ectopic gas in the mediastinum, subperitoneal abdomen, and superficial soft tissues is concerning and can be seen in the setting of trauma, iatrogenic injuries, infection, and inflammation. It can spread along different dissection pathways and may present remotely from the involved organ as described in part one. Recognition of ectopic gas on imaging and differentiating it from other causes of benign gas is very important as these conditions associated with ectopic gas can lead to rapid patient deterioration and usually require urgent surgery. In part two, the different causes of ectopic and benign gas in the torso are reviewed as well as the imaging features that can help to narrow the differential diagnosis.
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Affiliation(s)
- Claire K Sandstrom
- Department of Radiology, University of Washington, Harborview Medical Center, 325 Ninth Ave, Box 359728, Seattle, WA, 98104, USA.
| | - Sherif F Osman
- West Houston Radiology, 21214 Northwest Fwy #220, Cypress, TX, 77429, USA
| | - Ken F Linnau
- Department of Radiology, University of Washington, Harborview Medical Center, 325 Ninth Ave, Box 359728, Seattle, WA, 98104, USA
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Kim KS, Jeon HW, Moon Y, Kim YD, Ahn MI, Park JK, Jo KH. Clinical experience of spontaneous pneumomediastinum: diagnosis and treatment. J Thorac Dis 2015; 7:1817-24. [PMID: 26623105 DOI: 10.3978/j.issn.2072-1439.2015.10.58] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Spontaneous pneumomediastinum (SPM) is a benign disease with a variety degree of severity but definite treatment modality is not clearly identified with its rarity. The purpose of this study was to review our experience and discuss the management of SPM according to the severity of disease. METHODS From March 1996 to December 2012, total 64 patients were enrolled and classified as mild, moderate and severe groups and subsequent clinical courses were analyzed retrospectively. RESULTS Fifty-one were males and 13 were females (M:F =3.9:1) with a mean age of 18 years old (range: 10-30 years old). Thirty-six patients were in mild, 22 in moderate and 6 in severe group. Chief complaints were chest pain (50 cases; 78.1%), neck pain (35 cases; 54.7%), dyspnea (18 cases; 28.1%), odynophagia (9 cases; 14.1%) and precipitating factors were coughing in 12 cases, feeding problems in 9 cases, and vomiting in 7 cases; however, 34 patients (53.1%) had no precipitating signs. All patients received oxygen therapy (100%), prophylactic antibiotics in 57 patients (89.1%), and pain medications in 47 patients (73.4%). The mean hospital stay was 4.6 days (range: 1-10 days). There was an increased linear trend according to time to visit (P=0.023) but clinical course demonstrated no significant trend between groups. CONCLUSIONS These data demonstrated that there was no difference in symptom, clinical course and SPM was adequately treated with conservative management regardless of the degree of severity of SPM.
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Affiliation(s)
- Kyung Soo Kim
- 1 Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea ; 2 Department of Thoracic and Cardiovascular Surgery, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Republic of Korea ; 3 Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hyun Woo Jeon
- 1 Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea ; 2 Department of Thoracic and Cardiovascular Surgery, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Republic of Korea ; 3 Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Youngkyu Moon
- 1 Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea ; 2 Department of Thoracic and Cardiovascular Surgery, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Republic of Korea ; 3 Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Young Du Kim
- 1 Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea ; 2 Department of Thoracic and Cardiovascular Surgery, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Republic of Korea ; 3 Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Myeong Im Ahn
- 1 Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea ; 2 Department of Thoracic and Cardiovascular Surgery, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Republic of Korea ; 3 Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jae Kil Park
- 1 Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea ; 2 Department of Thoracic and Cardiovascular Surgery, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Republic of Korea ; 3 Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Keon Hyun Jo
- 1 Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea ; 2 Department of Thoracic and Cardiovascular Surgery, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Republic of Korea ; 3 Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Kim SH, Huh J, Song J, Kang IS. Spontaneous Pneumomediastinum: A Rare Disease Associated with Chest Pain in Adolescents. Yonsei Med J 2015; 56:1437-42. [PMID: 26256992 PMCID: PMC4541679 DOI: 10.3349/ymj.2015.56.5.1437] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Revised: 11/04/2014] [Accepted: 11/12/2014] [Indexed: 02/05/2023] Open
Abstract
PURPOSE Spontaneous pneumomediastinum (SPM) is a rare entity, with only a few cases reported, especially in adolescents. We aimed to analyze the clinical characteristics of SPM in adolescents and the diagnostic implications of computed tomography (CT) and esophagography therein. MATERIALS AND METHODS This retrospective descriptive study was conducted as a review of medical records of 416 adolescents (10-18 years of age) with chest pain from March 2005 to June 2013. Information on clinical presentation, methods of diagnosis, hospital stay, and outcomes were collected and analyzed. RESULTS Among adolescents complaining of chest pain, 11 patients had SPM (11/416, 2.64%). All patients presented with pleuritic chest pain, and 54.5% reported neck pain as the most common associated complaint. Clinical findings were nonspecific, and initial chest X-ray assessment was diagnostic only in three of 11 patients. However, reassessment of chest X-ray revealed diagnostic findings of SPM in five of the remaining eight patients. CT was diagnostic in all patients, while esophagography and echocardiogram were uninformative. Symptomatic improvement was noted within 2.45±1.2 hours (range, 0.5 to 4) after supportive care; mean hospital stay was 4.54±0.99 days (range, 2 to 6). No recurrence was observed. CONCLUSION SPM is a rare disease that should be considered in adolescent patients with pleuritic chest pain. Careful reading of initial chest X-rays is important to avoiding further unnecessary investigations. SPM is self-limited and treatment is supportive; nevertheless, if there are no indications of esophageal rupture, urgent esophagography is not recommended.
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Affiliation(s)
- Sung Hoon Kim
- Department of Pediatrics, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - June Huh
- Department of Pediatrics, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - Jinyoung Song
- Department of Pediatrics, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - I-Seok Kang
- Department of Pediatrics, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Zakaria R, Khwaja H. Subcutaneous emphysema in a case of infective sinusitis: a case report. J Med Case Rep 2010; 4:235. [PMID: 20678214 PMCID: PMC2920271 DOI: 10.1186/1752-1947-4-235] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2009] [Accepted: 08/02/2010] [Indexed: 11/25/2022] Open
Abstract
Introduction Subcutaneous emphysema with pneumomediastinum is a rare phenomenon with a high morbidity and may occur spontaneously. Case presentation A 30-year-old Caucasian man presented with sudden onset of a painful, swollen neck and was found, via clinical and radiological examination to have subcutaneous emphysema. A swallow study showed no oesophageal perforation. Computed tomography of his neck and thorax demonstrated pneumomediastinum but no other pathology. Management was conservative with intravenous antibiotics, fluids and no oral intake. He had a history of a productive cough and a flexible nasoendoscopy found purulent sinusitis which was treated with topical nasal washes. The patient was discharged after 72 hours and will be followed up by the otolaryngology-head and neck service. Conclusions Infective sinusitis is a rare cause of subcutaneous emphysema and pneumomediastinum. It may be managed conservatively provided there is early recognition and exclusion of more serious pathology, such as a ruptured trachea or oesophagus.
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Affiliation(s)
- Rasheed Zakaria
- Department of Surgery, Chelsea & Westminster NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, UK.
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