Tracheal stenosis due to endotracheal tube cuff hyperinflation: a preventable complication

Endotracheal intubation injuries are rare, but may be devastating-mostly among the pediatric patients or when these occur in the distal trachea. Such complications typify a therapeutic challenge, which, besides requiring intellectual and technical resources, takes a long time to reach a resolution. The authors present the case of a 15-year-old girl admitted with an abnormal state of consciousness due to diabetic ketoacidosis. She was submitted to endotracheal intubation with hyperinflation of the tube cuff, which rendered tracheal necrosis and detachment of the tracheal mucosa, and consequent obstruction. Later, she developed scarring retraction and stenosis. The patient was successfully treated with an endotracheal prosthesis insertion. The aim of this report is to illustrate a preventable complication.

Can total bronchopleural fistulas from complete stump dehiscence be endoscopically treated?

Objectives

Bronchopleural fistula (BPF) is an uncommon complication following a lung resection to address various conditions. BPFs are associated with high morbidity and mortality rates. This study evaluated the endoscopic treatment of 'total' BPFs using the Occlutech-Fígulla® cardiac device at a single centre.

Methods

We selected nine patients with chronic and complete BPFs. Under direct bronchoscopic visualization, the BPFs were treated using the Occlutech-Fígulla device. The patients were followed up for 12 months to determine the treatment level and complications.

Results

The procedure had a favourable outcome in three patients, resulting in complete fistula closure. Two patients had partial closure and showed improvements in their clinical conditions. In two other cases, closure of the bronchial stump was unsuccessful using this method. Two patients died from causes unrelated to the procedure or the device. During the follow-up period, no complications related to infection or device-related injuries were reported.

Conclusions

In patients without clinical conditions that require surgical treatment, the Occlutech-Fígulla cardiac device can be a safe and effective method for the endoscopic treatment of large BPFs resulting from complete dehiscence of a bronchial stump. No severe events were reported.

Is there a correlation between right bronchus length and diameter with age?

OBJECTIVE

Right main bronchial anatomy knowledge is essential to guide endoscopic stent placement in modern era. The aim is to describe right bronchial anatomy, cross-area and its relation with the right pulmonary artery and patient's age.

METHODS

One hundred thirty four cadaveric specimens were studied after approval by the Research and Ethics Committee at the University of São Paulo Medical School and Medical Forensic Institute of São Paulo. All necropsies were performed in natura after 24 hours of death and patients with previous pulmonary disease were excluded. Landmarks to start measurement were the first tracheal ring, vertex of carina, first right bronchial ring, and right pulmonary artery area over the right main bronchus. After mobilization, the specimens were measured using a caliper and measurement of distances was recorded in centimeters at landmarks points. All the measures (distances, cross sectional area and planes) were performed by three independent observers and recorded as mean, standard error and ranges. Student t test was used to compare means and linear regression was applied to correlate the measurements.

RESULTS

From 134 specimens studied, 34 were excluded (10 with previous history of pulmonary diseases, surgery or deformities and 24 of female gender). Linear regression showed proportionality between tracheal length and right bronchus length; with the area at first tracheal ring and carina and also between the cross sectional area at these points. Linear regression analysis between tracheal length and age (R=0.593 P<0.005), right bronchus length and age (R=0.523, P<0.005), area of contact between right bronchus and right pulmonary artery and age (R=0.35, P<0.005).

CONCLUSIONS

We can conclude that large airways grow progressively with increasing age in male gender. There was a direct correlation between age and tracheal length; as has age and right bronchus length. There was a direct correlation between age and the area of the right bronchus covered by the right pulmonary artery.

Endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis and staging of mediastinal lymphadenopathy: initial experience in Brazil

OBJECTIVE

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a new method for the diagnosis and staging of mediastinal lymph nodes. The objective of this study was to evaluate the preliminary results obtained with EBUS-TBNA in the diagnosis of lesions and mediastinal lymph node staging.

METHODS

We evaluated patients with tumors or mediastinal adenopathy, diagnosed with or suspected of having lung cancer. The procedures were performed with the patients under sedation or under general anesthesia. Material was collected by EBUS-TBNA, after which it was prepared on slides, fixed in either absolute alcohol (for cytology) or formalin (for cell-block analysis).

RESULTS

We included 50 patients (30 males). The mean age was 58.3 ± 13.5 years. We performed 201 biopsies of 81 lymph nodes or mediastinal masses (mean of 2.5 punctures/biopsy). The quantity of material was considered sufficient for cytology in 37 patients (74%), 21 (57%) of whom were thus diagnosed with malignancy. Of the remaining 16 patients, 1 was diagnosed with tuberculosis, 6 entered clinical follow-up, and 9 underwent further investigation (2 diagnosed with neoplasm-false-negative results). The yield was higher when the procedure was performed for diagnostic purposes, as well as being higher in patients with lesions in multiple stations and in biopsies involving the subcarinal lymph node station. One patient had endobronchial bleeding, which was resolved with local measures. There were no deaths among the patients evaluated.

CONCLUSIONS

This preliminary experience shows that EBUS-TBNA is a safe procedure. Our diagnostic yield, although lower than that reported in the literature, was consistent with the learning curve for the method.

Suspension laryngoscopy for the thoracic surgeon: when and how to use it

Suspension laryngoscopy is one of the most common otolaryngological procedures for the diagnosis and surgical approach to the larynx. However, most thoracic surgeons are not familiar with the procedure and seldom use it. The indications for its use are similar to those for that of rigid bronchoscopy (dilatation, endoprosthesis insertion, and tumor resection). It can be performed in children and adults. Suspension laryngoscopy is an alternative when rigid bronchoscopy is unavailable and is therefore a viable option for use at smaller facilities. In this communication, we describe the technique and the applications of suspension laryngoscopy in thoracic surgery.

Tratamento endoscópico de fístulas da árvore traqueobrônquica com dispositivos para a correção de defeitos do septo interatrial: resultados preliminares

As fístulas da árvore traqueobrônquica, sejam elas broncopleurais ou traqueoesofágicas, apresentam etiologia multifatorial, com incidência variável na literatura. Em geral, apresentam alta morbidade e mortalidade, com indicação formal de correção cirúrgica. Entretanto, a condição clínica dos pacientes muitas vezes não permite uma reintervenção cirúrgica de grande porte. Além disso, as tentativas de fechamento endoscópico raramente têm sucesso, principalmente em fístulas de grande diâmetro. Relatamos os casos de três pacientes submetidos ao fechamento endoscópico de fístulas, sendo duas maiores que 10 mm, com a aplicação de dispositivos oclusores utilizados na cardiologia intervencionista, de forma minimamente invasiva e com resultados iniciais positivos. Esses dados sinalizam que essa pode ser uma técnica promissora na resolução de fístulas da árvore traqueobrônquica.

Tumour cell and stromal features in metastatic and non-metastatic non-small cell lung carcinomas

AIMS

Tumour cell behaviour depends on the interactions between nuclear genetic changes in the malignant cells and a stroma favourable for growth, invasion and metastasis. To evaluate such interactions, we studied the relationship between tumour cell and stromal features for proliferative factors, p53, microvessel density and metalloproteinases, controlled for the extent of the primary lesion (T1 to T4), in early (non-metastatic) and late (metastatic) non-small cell lung carcinomas (NSCLC).

METHODS AND RESULTS

Variables were examined for differences and correlations in the frequency of p53, AgNOR, CD34 and MMP-9 expression in primary lesions and metastases of NSCLC using a general linear model. The patients included 58 males and 22 females (mean age 62 +/- 9 years) with 19 T1 (23.8%), 40 T2 (50.0%), 14 T3 (17.5%) and seven T4 (8.8%). In late disease, AgNOR and p53 were statistically related to the extent of the primary lesion, whereas in early disease AgNOR tended to be increased in tumours without metastasis, while p53 expression tended to decrease progressively in tumours with metastasis. Microvessel density in late disease was of no statistical significance, whereas in early disease strong CD34 expression was seen in tumours with metastasis, being at its maximum in T3 primary lesions. The best marker for the extent of the lesion and its progression was MMP-9, with greater expression by tumours with metastasis than those without.

CONCLUSIONS

Different tumour cell and stromal interactions control metastasis and therefore the biological risk of NSCLC. A panel of molecular markers, such as p53, MMP-9 and CD34 could help to identify subgroups of patients that could benefit from adjuvant therapy.

Recognition memory in normal aging and Parkinson's disease: behavioral and electrophysiologic measures

To assess effects of normal aging and Parkinson's disease (PD) on recognition memory, we examined the N400 component of event-related potentials (ERPs) and behavioral measures during a recognition memory task in 17 normal young subjects, 17 normal elderly subjects, and 17 patients with PD. To elicit ERPs, some words were repeated immediately after initial presentation (at lag 0), while others were repeated after one intervening word (at lag 1) or at lag 6. Subjects were requested to push a button with the right thumb upon first presentation of a word and with the left thumb upon repeat presentation. Compared to the normal young subjects, normal elderly subjects showed reduced accuracy in recognizing repeated words at lags 1 and 6. Compared to the normal elderly group, PD patients showed decreased accuracy in recognizing lag 6 repetition. N400 amplitude did not differ between the two normal groups, while PD patients showed lower N400 amplitudes than normal elderly subjects. The N400 in the young group showed attenuation for lags 0, 1 and 6 repetitions, while attenuations in the elderly group and the PD group were noted only for lags 0 and 1 repetitions. These data suggest intact immediate but impaired delayed recognition memory in aging and in PD. In addition, recognition memory deficits in PD may result, at least partly from the impairment of context integration process.

Auditory event-related potentials in an amnesic patient with a left temporal lobe lesion

We studied auditory event-related potentials (ERPs) in correlation with Rey's auditory verbal learning test (AVLT) in an amnesic patient with a left temporal lobe lesion. On the AVLT, the number of words recalled was limited to immediate memory capacity (nine words) throughout five trials, and recall after interference was remarkably decreased. In the ERPs, the P300 component was elicited normally, but no N400 component was apparent. Present findings suggest that these two ERP components may be associated with independent processes and support the view that the N400 may index a neural process involved in transfer of information from immediate memory to long-term storage.

Descending necrotizing mediastinitis: a retrospective surgical experience

OBJECTIVE

Descending necrotizing mediastinitis (DNM) is a primary complication of cervical or odontogenical infections that can spread to the mediastinum through the anatomic cervical spaces. We reviewed the last 10 years of our surgical experience in DNM and commented on early diagnosis and aggressive surgical treatment in these patients.

METHODS

Five males (71%) and two females (29%), mean age 34 years, with DNM, were surgically treated. Primary oropharyngeal infection occurred in three (43%) and odontogenic abscess in four (57%) patients. All had serious cervical and mediastinal infections with severe respiratory and hemodynamic repercussions, i.e. bacteremia, systemic arterial hypotension and obnubilation. Diagnosis was confirmed by computerized chest tomography.

RESULTS

All patients underwent surgical drainage of the cervical region by bilateral transverse cervicotomy with debridement of the necrotic and infected tissues, associating ample mediastinal drainage with or without thoracotomy. Six patients (86%) evolved well and were discharged after a mean of 35 days. Two patients (29%) required reoperation due to local surgical complications: empyema and dehiscence of the sternum. One patient (14%) died on the second postoperative (p.o.) day due to renal and respiratory insufficiency. Cultures of DNM showed the development of associated aerobic and anaerobic flora in 71% of the operated patients and only aerobic in 29%.

CONCLUSION

Early diagnosis by CAT scan of the neck and thorax aids in rapid indication of a surgical approach of DNM. Performing ample cervicotomy with mediastinal drainage generally associated with thoracotomy can significantly reduce the mortality rate for this condition to 14%.

Memory in patients with subcortical infarction--an auditory event-related potential study

Event-related potentials (ERPs) were recorded from 21 patients with subcortical infarction (mean age, 62.1 years) and 14 normal control subjects (mean age, 62.7 years) as they listened to lists of words or pronounceable non-words. Some words were repeated immediately after initial presentation (lag 0), while others were repeated after five intervening words (lag 5), or after 2 to 4 min (lag 11-77). The subjects were asked to push a button upon hearing the occasional non-words. The Auditory-Verbal Learning Test (AVLT) also was administered to the patients to examine explicit memory. The mean N400 amplitude, appearing between 300 and 800 ms after the stimulus, was smaller in patients with subcortical infarction than in control subjects. The N400 in response to repeated words at lags 0, 5 and 11-77 was attenuated for both the patient and control groups. On the AVLT the total number of recalled words and number of words after interference were significantly decreased in patients relative to controls, while recognition was relatively preserved. The results suggest that lexical processing and retrieval mechanism of explicit memory are disturbed in patients with subcortical infarction, but implicit memory measured by this N400 paradigm is relatively preserved.

Repair of congenital sternal cleft in infants and adolescents

BACKGROUND

Clinical and surgical aspects of sternal cleft repair are presented. Primary repair in the neonatal period is the best management for this rare condition, but none of the patients in this report were referred to us during that period. Autologous repair is suitable for older patients because it avoids problems related to the implant of prosthetic materials.

METHODS

This article reviews 8 cases of sternal cleft not associated with ectopia cordis in patients presenting between October 1979 and November 1997. Surgical repair consisted of three sliding chondrotomies, three posterior sternal wall repairs, one combination with the Ravitch technique for pectus excavatum repair, and one posterior sternal wall repair associated with total repair of Cantrell's pentalogy.

RESULTS

All patients who submitted to surgical correction had good aesthetic and structural results. The postoperative period was uneventful except that a subcutaneous fluid collection developed in 1 patient. The mean hospital stay was 5.8 days. The patients were followed up from 4 months to 18 years.

CONCLUSIONS

Whether dealing with older children or young adults, the technique of reconstructing a new sternum with a posterior periosteal flap from sternal bars and chondral grafts is a simple, quick, inexpensive, and effective option.

Prognostic significance of argyrophilic nucleolar organizer region (AgNOR) in resected non-small cell lung cancer (NSCLC)

The expression of the nucleolar organizer regions (NORs) was quantified in paraffin sections of tumors and lymph node metastasis, by means of digital image analysis, in 75 patients with resected non-small cell lung cancer (NSCLC). Patients were divided in two groups: early stage (stages I and II) and advanced stage (stages IIIa, IIIb and IV). The prognostic significance of AgNOR expression was tested by Cox regression analysis in models controlled for age, sex, vital status, stage and histological type. Tumors at early stages had a lower expression of AgNOR than those at more advanced diseases. The mean values obtained for NORs in advanced disease were almost the same as those in the primary tumors when compared with the corresponding lymph node metastasis (r = 0.90; p < 0.01; linear regression). The prognostic role of AgNOR was significant only for tumors at stages I and II and not for advanced neoplasms (stages IIIa, IIIb and IV). These results encourage the inclusion of AgNOR quantitation in routine material, especially in early lung cancer.

Human pulmonary dirofilariasis: analysis of 24 cases from São Paulo, Brazil

STUDY OBJECTIVE

To present the clinical, radiologic, and pathologic aspects of 24 cases of human pulmonary dirofilariasis (HPD) from São Paulo, Brazil.

DESIGN

Retrospective study of 24 patients with a confirmed diagnosis of HPD over a 14-year period (from February 1982 to June 1996).

SETTING

Thoracic Surgery and Pulmonary Division, University of São Paulo and Hospital Albert Einstein, São Paulo, Brazil.

RESULTS

Seventeen patients were male (70.1%) and seven were female (29.9%). Their mean age was 51.4 years. Fifty-four percent of the patients were asymptomatic and 75% had a well-circumscribed noncalcified peripheral subpleural pulmonary nodule on the chest radiograph and thoracic CT scan, located preferentially in the lower lobes. The diagnosis was made after thoracotomy and wedge resections in 16 patients, by videothoracoscopy in six, after a pleural biopsy in one, and after necropsy in one. The pathologic examination of all the nodules revealed a central zone of necrosis, surrounded by a narrow granulomatous zone and peripherally by fibrous tissue. Pulmonary vessels exhibit varying degrees of endarteritis. In all cases, a dead worm, usually necrotic and fragmented, was found.

CONCLUSIONS

A subpleural, noncalcified pulmonary nodule in the appropriate clinical and epidemiologic setting should alert the clinician, radiologist, or pathologist to the possibility of Dirofilaria. HPD should be considered in the differential diagnosis of pulmonary nodules.

Thoracoscopy in children and adolescents

STUDY OBJECTIVES

Present the feature characteristics of the use and findings of thoracoscopy in children and adolescents.

DESIGN

From February 1983 to February 1996, 77 thoracoscopic procedures were done on patients ranging in ages from 5 months to 18 years (mean, 9.8 years). Two-thirds (66.2%) were male. They were divided into three groups (1, 2, and 3) based on age (up to 2, from 2 to 8, and older than 8 years), predominance of certain diseases in these ages, and the size of the instruments utilized. They were operated on using general anesthesia with Carlens' mediastinoscope routinely used in 64 (83%) and videothoracoscopy in 13 (17%). The chief indication for therapeutic thoracoscopy was treatment of empyema, while for diagnostic thoracoscopy it was pleural biopsy and diagnosis of pleural effusions.

RESULTS

In group 1, thoracoscopy was solely for the treatment of pleural disorders. In group 2, it was for the treatment of pleuropulmonary diseases. Group 3 behaved almost like adults, with broad diagnostic and therapeutic indications for thoracoscopic procedure.

CONCLUSIONS

Thoracoscopy, which is a useful diagnostic and therapeutic procedure, has secured an important place in pediatric surgical practice.

Thoracoscopic surgery in Brazil. An overview

The Video Assisted Thoracic Surgery (VATS) was introduced in Brazil in 1992 by Losso, Ghefter and Imaeda. Since its advent up to November 1994, 488 patients have been submitted to 497 VATS procedures in four Medical Centers of São Paulo city. The indications for the procedures were: lung diseases in 244 patients (50%), pleural disease in 155 patients (31.7%), thoracic traumas in 42 patients (8.6%), mediastinal diseases in 35 patients (7.1%), cardiovascular diseases in 7 patients (1.4%), chest wall diseases in 3 patients (0.6%) and esophageal diseases in 2 patients (0.4%). In the group of lung disease the most commonly used procedures were the lung biopsy in order to diagnose diffuse pulmonary disease and the indeterminate solitary nodule resection. Among the occurrences of pleural diseases, the most commonly used procedures were the pleurodesis with talc (talc poudrage) for the treatment of recurrent pleural effusion, the driven pleura biopsy and debridment or decortication of trapped lung in cases of pleural empyema. Concerning the mediastinal diseases, the pathology which was most frequently treated by VATS was the recurrent pericardic effusion through partial pericardiectomy. Among the patients presenting chest traumatic diseases, the VATS was used to explore thoracoabdominal penetrating injuries, to control bleeding, to remove clotted hemothorax, to suture diaphragm lesions and to remove intrapleural foreign bodies. Out of 497 procedures, there were 28 convertions to thoracotomy (5.7%) and two deaths occurred all over the cases. The complications, limitations and growth related to this method as well as a future overview of the VATS in Brazil will be presented.

Mitochondrial encephalomyopathy with elderly onset of stroke-like episodes

A 52-year-old woman with a history of a hearing disturbance since age 20 experienced visual hallucinations and convulsions, followed by right hemiparesis and aphasia. On the basis of a muscle biopsy and mitochondrial DNA analysis, she was diagnosed as mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS). This case is unique in that the stroke-like episodes occurred 30 years after disease onset.

[Lung cancer and the delay in the diagnosis: analysis of 300 cases]

This is a prospective study involving 300 persons with lung cancer admitted to the "Arnaldo Vieira de Carvalho" Cancer Institute (ICAVC). The intention of the survey was to detect delay in diagnosis after the initial symptoms. THe authors tried to identify causes of this delay and its implications. Patients were asked about the day that the symptoms started, medical care and specialists sought, number of physicians seen and their diagnosis, also examinations carried out and referrals. Results showed that 78% of cases were seen firstly by general practitioners and 69.6% looked for medical assistance at least 30 days after the clinical beginning of the disease. Chest X-rays could identify only 9 cases (3%) without symptoms. The most common clinical diagnoses were: pneumonia (20%), neoplasia (19%), bronchitis/emphysema (9.3%) and tuberculosis (8%). The number of first appointments seen by the Public Health Services and Contracted Private Hospital Network was 64.1% and the second appointment was 70%. Only 24 (8%) of the patients were referred to ICAVC just after their first appointment and 64.4% after the third. The time lost between the first appointment and the diagnosis was longer than 90 days in 55.7% of cases. These people needed to see 3 to 4 doctors (as an average) to obtain a positive diagnosis. The diagnostic techniques used more frequently were bronchoscopy (59.7%) and fine needle lung biopsy (18.4%) and the delay was 20 and 10 days on average, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

[Delay factors in the diagnosis of lung cancer: a public health problem]

The authors try to identify causes of delay in the diagnosis of lung cancer, such causes being liable for low survival rates in five years. With this in mind, they developed a prospective study involving 100 patients admitted to the "Arnaldo Vieira de Carvalho" Cancer Institute, who were asked as to the date symptoms started, medical care searched, first diagnostic impressions, and number of physicians seen till the moment of diagnosis. They observed that 73 patients looked for medical assistance up to the 30th day from the beginning of disease, and only in 10 occasions this interval was longer than 120 days. 46 patients had a confirmed diagnosis in less than 90 days after their first medical appointment, and in 41 cases the delay in diagnosis was longer than 4 months. Upon the first exam with the physician, neoplasia was suspected 25 times, but only 11 patients were immediately referred to the Cancer Institute. Of the remaining 89 patients, 57 were referred only after their third medical appointment. 80 patients were first seen by general practitioners and, on average, patients went to 3 or 4 physicians to obtain a definite diagnosis. The most commonly used method to identify neoplasia was bronchofibroscopy (67 cases), with an average of 20 days of delay for its performance. Lung biopsy using transparietal fine needle was the second most used (14 cases), with an average delay of 10 days. The authors conclude that delay in the diagnosis is mostly due to the inadequacy of medical services, delay in referrals and in the performance of subsidiary tests.(ABSTRACT TRUNCATED AT 250 WORDS)