Prevention of arrhythmias by flecainide after noncardiac thoracic surgery

Cardiac arrhythmias are a frequent complication after thoracic operations. The prophylactic value of flecainide administered as a constant-rate, intravenous infusion (0.15 mg/kg/h) after a loading dose (2 mg/kg) was tested in a randomized, placebo-controlled study in 30 patients using Holter monitoring during the first 72 hours after operation. A high incidence of atrial and complex ventricular arrhythmias was observed in the placebo-treated group, with a clear predominance in patients undergoing left thoracotomy. Antiarrhythmic drugs had to be added in 6 patients in the placebo-treated group (n = 16), but in none in the flecainide-treated group (n = 14) (p less than 0.01). The preventive effect of flecainide was observed at serum concentrations in the middle of the therapeutic range (409 ng/mL) without side effects. It is concluded that flecainide administration effectively reduced or prevented cardiac arrhythmias after thoracic operations.

A technical modification of median sternotomy to eliminate subxiphoid incisional hernias

A modification of the standard median sternotomy incision that avoids division of the xiphoid process and the linea alba has been used for ten years, to our knowledge, without occurrence of an incisional hernia.

Simultaneous occurrence of chylothorax and subarachnoid pleural fistula after thoracotomy

A left chylothorax complicated elective left posterolateral thoracotomy and emergency decompressive laminectomy carried out on a 32-year-old woman with a benign neurofibroma. Failure of conservative therapy necessitated ligation of the thoracic duct and this in turn unmasked the concomitant subarachnoid-pleural fistula. Surgical repair and lumbar subarachnoid drainage were required to close the second fistula. The clinical setting, diagnosis and management of this uncommon condition are reviewed.

Emergency room thoracotomy for stab wounds to the chest and neck

This study group comprises 73 patients who underwent emergency room resuscitative thoracotomy for cardiac arrest following penetrating chest and neck injuries. Overall, 12 patients (16.4%) were successfully resuscitated but only five (6.8%) left the hospital alive without neurologic defects. None of the 18 cases with no vital signs at all (no cardiac activity, no respiratory efforts, nonreactive pupils) on admission survived. Only one out of the 19 cases with no cardiac activity and with fixed pupils but present respiratory efforts survived (5.3%). Of 14 patients with cardiac arrest but with respiratory efforts and reactive pupils, three survived (21.4%). We suggest that patients with no vital signs on admission to the hospital should not be subjected to resuscitative thoracotomy.

The contribution of anterior mediastinotomy in the diagnosis and evaluation of diseases of the mediastinum and lung

Our experience with 62 consecutive patients who underwent anterior mediastinotomy is presented. A wide range of histological diagnoses was achieved. The highest yield was achieved for mediastinal masses. The overall diagnostic specificity was 64.5% and the diagnostic sensitivity was 98%. However, patient morbidity and mortality were 16.1% and 1.6%, respectively. Therefore, specific guidelines for the procedure are presented.

Spontaneous pneumothorax

Spontaneous pneumothorax is not uncommon and can be potentially dangerous, especially in older people. A series of 201 patients is presented. Conservative treatment with tube thoracostomy had a 19% failure rate. It seems nevertheless to be the treatment of choice, though with risk of serious complications. Among the 60 patients who underwent lateral thoracotomy, 30% had recurrence of pneumothorax or other complications. Reoperation because of inadequate pulmonary expansion was necessary in four cases.

Intrathoracic desmoids: report of two cases

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Emergency thoracotomy for injury

Emergency thoracotomy is required in 10-15 per cent of all patients with thoracic injury. Nine specific indications for emergency thoracotomy have been described for injured persons. A variety of incisions is available to the surgeon, and selection of the appropriate incision is based on radiographic and clinical findings. Thoracotomy in the emergency room is occasionally indicated, but it should be performed only by surgically trained individuals. Patients requiring emergency thoracotomy who are not dead on arrival have a greater than 75 per cent chance of survival.

Complications associated with thoracocentesis

In order to determine the spectrum and frequency of complications associated with thoracocentesis, we decided to audit prospectively all thoracocentesis performed in the medical service at our institution. Over a ten-month interval, 125 procedures were performed. We identified 114 (91 percent) prospectively, 11 retrospectively by a computer-assisted review of discharge summaries. Forty-six percent of the procedures were complicated by at least one adverse occurrence. Complications considered major occurred in 14 percent, minor in 33 percent. The major complications included 14 pneumothoraces (three required tube thoracostomies and one percutaneous aspiration), one splenic laceration, one sheared-off catheter, and one pneumohemothorax. The minor complications included pain in 28, persistent cough in 14, dry taps in 16, and subcutaneous fluid collections in four patients. We conclude that thoracocentesis can carry the risk of frequent morbidity even when a lecture and printed guidelines on performing thoracocentesis have been given and experienced individuals are in attendance during the performance of the procedure. Our study suggests a portion of this morbidity may be from poor technique, inability to adequately identify landmarks, and improper utilization of a needle-catheter apparatus. Suggestions for correction of these problems are made.

False aneurysm formation: a complication following the modified Blalock-Taussig shunt

False aneurysm formation is a rare complication of the modified Blalock-Taussig shunt. A patient is described in whom this complication arose 11 months after operation. Death resulted from rupture of the aneurysm into the right lung with associated massive hemoptysis. The onset of hemoptysis in patients with a functioning modified Blalock-Taussig shunt may be the first evidence of a developing false aneurysm.

Chest-tube thoracostomy causing Horner's syndrome

Horner's syndrome developing early after lung biopsy is reported in a 42-year-old woman. At the end of the procedure a thoracostomy tube was inserted with its tip at the T1-2 posterior intercostal space. The authors conclude that direct injury to the second order preganglionic neuron in the vicinity of the stellate ganglion caused the Horner's syndrome. They recommend placing the tip of the thoracostomy tube below the level of the second rib posteriorly to prevent this complication.

Breast and pectoral muscle maldevelopment after anterolateral and posterolateral thoracotomies in children

Anterolateral and posterolateral thoracotomies, involving an incision through the third and fourth intercostal space, have been used for the repair of congenital heart lesions in children during the past thirty years. We examined 28 patients who had undergone repair of atrial septal defect, patent ductus arteriosus, and coarctation of the aorta as children, through the anterolateral or posterolateral chest approach. Volumes of the breasts and pectoral muscles were obtained by a method using plaster molds, and linear dimensions of each chest side were measured. Questionnaires were completed that delineated the patients' perception of asymmetry of the chest. Infant breast tissue on cadavers was examined. We conclude that standard anterolateral thoracotomies result in a high frequency of breast or pectoral maldevelopment; 60% of our patients had a greater than 20% difference in volume between the two sides. We propose a modified operative approach that we believe will reduce the frequency of maldevelopment.

Diplopia and pneumoencephalocoele after chest wall resection and intraoperative radiation therapy

The dural sheath may be transected in the course of a posterior thoracic procedure. If air is introduced into the subarachnoid space, a cranial nerve palsy may result. Computed tomographic scanning establishes the diagnosis. The condition resolves without treatment.

Twenty-eight cases of human heart-lung transplantation

Between March, 1981, and August, 1985, twenty-eight heart-lung transplant operations were done in 27 patients at a single institution. 8 patients died in the perioperative period and adhesions related to previous thoracic surgery proved to be a major risk factor for postoperative haemorrhage. Obliterative bronchiolitis developed in half of the 20 long-term survivors, a mean of 11.2 months (range 2-35 months) after surgery: 4 of these patients died, 3 are functionally limited, 2 were successfully treated with corticosteroids, and the remaining patient was successfully retransplanted. The other 10 long-term survivors returned to a normal life with essentially normal pulmonary function measured at a mean of 22.6 months (range 4-42 months) after transplantation. All the surviving patients have evidence of renal impairment related to cyclosporin nephrotoxicity. The results indicate that, although heart-lung transplantation is compatible with essentially normal long-term pulmonary function, the procedure should not yet be regarded as a routine clinical intervention.

Catheter aspiration for simple pneumothorax (CASP) in the outpatient management of simple traumatic pneumothorax

Catheter aspiration for simple pneumothorax (CASP) was evaluated prospectively in the outpatient management of simple traumatic pneumothorax in 17 patients and compared to conventional tube thoracostomy (CTT) in 17 matched control patients. In 16 of the 17 consecutive study patients CASP maintained lung reexpansion without complications. Pneumothorax was due to needle puncture for drug abuse in 11 patients, stab wounds in five patients, and blunt trauma in one patient. The CASP patients were not hospitalized, whereas the control CTT patients averaged 4.9 days' hospitalization. CTT was associated with complications in two patients versus none for CASP. Parenteral analgesics were utilized for greater than 48 hours in CTT patients but were not needed for CASP patients. Costs averaged +310 for CASP compared to +3,030 for CTT. This ongoing pilot study data indicates that CASP is a reasonable alternative to CTT in selected patients with simple traumatic pneumothorax.

The risk of percutaneous chest tube thoracostomy for blunt thoracic trauma

Analysis of 164 percutaneous chest tube thoracostomies performed as a standardized technical procedure in the management of 129 blunt trauma victims demonstrated an overall complication rate of 9.1% (15 of 164). Three complications (1.8%) were related to problems of insertion, and four (2.4%) represented the problem of pneumothorax after chest tube removal. The remaining eight complications (4.9%) were associated with positive bacterial cultures, two (1.2%) of which represented clinical empyema. Both cases of empyema had either prolonged chest tube placement (23 and 15 days) or multiple chest tubes (two and three) on the same side. Percutaneous chest tube thoracostomy remains an important facet in the management of certain types of blunt thoracic trauma. Associated risks can best be minimized with adherence to a standardized technique and management protocol.

Progressive scoliosis following chest wall resection in children

The effect of partial chest wall resection on subsequent production of spinal deformity was studied in six pediatric patients. The following observations are made: Scoliosis secondary to chest wall resection in the pediatric age group is progressive. The degree of curvature is related to the number of ribs resected. Anterior resection of ribs does not produce significant scoliosis, whereas resection of the posterior aspect of the ribs promptly produces scoliosis. Scoliosis associated with marked pleural thickening secondary to recurrent tumor, irradiation scarring, and underlying pulmonary metastases is always convex toward the normal side. Scoliosis associated with empyema and chest wall osteomyelitis is likewise convex toward the normal side and may respond to removal of this thether in the growing child.

Early thoracotomy and decortication for nontuberculous empyema in adults with and without underlying disease. A twenty-five year review

The present review deals with 63 adult patients having acute nontuberculous empyema treated by early thoracotomy and decortication, during the period from 1955 through 1979. Group I (38 patients) had postpneumonic empyema, but no underlying disease. Group II (25 patients) had acute empyema and one or more serious associated diseases. Positive cultures were present in 45 of 63 patients (71.4%). Most surgeons have customarily recommended conservative management, especially for patients in Group II, because of the supposedly "high risk" involved in decortication. Consequently, the mortality is extremely high. The empyema must be cured; a "well drained" or "controlled" empyema will not suffice. The severely ill patient can better withstand the ordeal of a major operation than the deleterious effects of a lingering empyema. The critically ill patient is best managed by the primary procedure of open thoracotomy and decortication. The author's experience confirms that such patients can expect an outlook (8% mortality) approaching the zero mortality of Group I patients.

Deep-vein thrombosis after major non-cardiovascular thoracic surgery

The incidence of deep-vein thrombosis (DVT) verified by fibrinogen test was studied in 44 high-risk patients after major non-cardiovascular thoracic surgery. In eight patients (18%) a total of ten DVT appeared within the first postoperative week. Four thrombi were located at or above knee level. More extensive surgery was associated with higher DVT incidence than lesser operations (32% v. 8%). In patients belonging to blood groups B and AB, DVT was more common than in other blood groups. Five of the six unilateral DVT were detected on the same side as the thoracotomy. The findings suggest that DVT incidence after this kind of surgery may be of the same order as after major general surgery, indicating a need for thromboprophylactic measures.

[Auricular flutter after cardiothoracic surgery. Treatment by auricular stimulation using the esophageal approach]

Transoesophageal atrial pacing was used in 10 patients to interrupt post-operative atrial flutter after cardio-thoracic surgery. The method was successful in all cases. The arrhythmia was converted directly into sinus rhythm in 8 patients and into atrial fibrillation followed by spontaneous reversion to sinus rhythm in 2 patients. The results differed according to the underlying disease. Return to sinus rhythm was the rule in all patients who underwent coronary artery bypass grafting and pneumonectomy, whereas transient atrial fibrillation seemed to be more frequent (and should be considered a satisfactory result) in patients with heart valve surgery. Relapses of arrhythmias seemed to be more resistant to transoesophageal stimulation irrespective of the operation performed. The method is non-invasive, easy to carry out and safe in patients receiving digitalis. The risk of ventricular pacing is very low. The burning sensation and chest pain experienced during stimulation are well tolerated. Transoesophageal pacing is as effective as epicardial atrial stimulation and more effective in such patients than temporary transvenous atrial pacing.

[Infections in surgery under extracorporeal circulation. Results of 3 years of antibioprophylaxis]

The present study was designed to evaluate perioperative antibio-therapy with cefamandol for the prevention of post-operative infections after surgery under cardiopulmonary bypass. 1 300 patients were studied. The incidence for wound infections was 1.3%, 0.9% for systemic, 1.3% for other infections. These results show a decrease in the frequency of infections in comparison with data from the literature.

Galactorrhea secondary to chest wall surgery in an adolescent

Although nonpuerperal galactorrhea in youth may be a sign of pituitary prolactinoma, the etiology may be benign and extensive neurologic or endocrinologic evaluation and treatment may be unnecessary. An 18-year-old female with an unusual but benign form of transient galactorrhea due to chest wall surgery is reported. It is hypothesized that the sectioning of the intercostal nerves may result in reflex stimulation of hypothalamic centers controlling lactation through the same neural pathways involved in puerperal lactation. The patient experienced galactorrhea for two months and transient amenorrhea. She is asymptomatic without galactorrhea at nine months follow up.

Chylothorax--a complication of chest tube placement in a neonate

A premature infant with respiratory distress syndrome developed a left chylothorax after evacuation of a left tension pneumothorax. The Argyle catheter noted in the posterosuperior mediastinum possibly traumatized the thoracic duct. Although the infant's chylothorax resolved with conservative management, he subsequently died of severe bronchopulmonary dysplasia. The potential complication of chylothorax from thoracostomy tubes can be prevented by avoiding penetration into the posterosuperior mediastinum.

Pain amelioration after thoracotomy: a prospective, randomized study

Twenty patients undergoing a posterolateral thoracotomy for lung resection or a nonpulmonary procedure were divided into four groups. Group 1 was the control group. Patients in Group 2 had an intercostal nerve block at the time of closure. Those in Group 3 underwent a continuous intercostal nerve block for five days. Electronic pain control was used in Group 4. An additional group of patients underwent operation through an anterolateral thoracotomy (Group 5) and was compared with the control group. Breathing performance was evaluated daily for five days with bedside spirometry, and intergroup comparison was done utilizing the unpaired t test and analysis of variance. Forced expiratory volume in one second, expressed as percent of preoperative values, was significantly better in Group 3 (continuous intercostal nerve block) at 52.4 +/- 9.2% (standard deviation; p less than 0.05) and in Group 5 (anterolateral thoracotomy) at 52.0 +/- 7.5% (p less than 0.05) than in the control group (38.4 +/- 8.8%) five days postoperatively. It is concluded that bedside spirometry is a simple and reliable technique to assess postoperative changes in ventilatory mechanics due to pain. The pain that follows posterolateral thoracotomy can be substantially decreased with a continuous intercostal nerve block. Anterolateral thoracotomy is notably less painful than posterolateral thoracotomy and should be considered the approach of choice for patients with decreased pulmonary reserve who undergo uncomplicated pulmonary resection.

[Detection of venous thrombosis of the legs by the iodine 125-labeled fibrinogen test in thoracic surgery. Apropos of 140 surgically-treated cases]

The tracing of venous thromboses of the lower limbs by means of iodine 125 marked fibrinogen is possible in thoracic surgery thanks to the calibration of the apparatus on the femoral surface in cases of left thoracotomy or sternotomy. Twelve patients out of 128, i.c. 9.4%, had a positive test: 11 men and 1 woman of whom 11 had a minimum of 2 risk factors of venous thrombosis. These patients had 7 right and 5 left thoracotomies: 6 pneumonectomies (15.4% of pneumonectomies), 5 lobectomies (13% of lobectomies) and one enucleation; 11 positive tests occurred on patients operated on for cancer. There were 5 thrombo-embolic accidents: 2 fatal and 2 non fatal. Mortality was 4.28%: 6 patients of whom 3 died of infectious causes and 3 of pulmonary embolism: 2 after a pneumonectomy, respectively at 2 days and 2 months, and 1 after a lobectomy at 5 days. This examination was useful to known our percentage of isotopic thrombosis of the lower limb after thoracotomy: 9.4% which is small compared with those of the literature. However these results show the importance of instituting more prophylactic procedures to prevent venous thrombosis and thromboembolism by using heparin in all patients operated an for cancer with an exeresis and presenting 2 or more risk factors of venous thrombosis.

Respiratory care of the surgical patient with cardiac disease

This article describes the mechanisms by which cardiac disease, when combined with surgery and anesthesia, may tax the respiratory system beyond its capabilities. Techniques of respiratory support aimed at improving oxygenation, ventilation, and the work of breathing are examined.

Tapia's syndrome after thoracotomy

Tapia's syndrome, a unilateral paralysis of the muscles of the tongue associated with palsy of the ipsilateral vocal cord, was observed in two patients within a short time of each other, after they had undergone thoracotomy. It can be understood as an extremely localized lesion just at the crossing of the vagal and hypoglossal nerves. Pressure neuropathy of both nerves due to inflation of the cuff within the larynx is an accepted cause. An alternative explanation is that stretch, caused by downward traction of the esophagus, is transferred to both nerves, those being closely connected in many places, and ultimately causing damage to them.

Scoliosis after thoracotomy for esophageal atresia

Progressive scoliosis was seen in eight children after thoracotomy for esophageal atresia. Postoperatively, all had had severe mediastinitis and empyema secondary to dehiscence of the esophageal anastomosis and required reoperation. Healing was accompanied by marked scarring and rib fusion; with growth, a scoliosis developed with the concavity toward the thoracotomy site. Most spinal curvatures appeared years after the thoracotomy and progressed rapidly at the time of adolescent growth spurt. Excision of fused ribs, spinal fusion, and instrumentation led to improvement in four patients.

Pneumothorax, hemothorax, and other abnormalities of the pleural space

The clinical setting and treatment of various types of pneumothorax are detailed; chylothorax and hemothorax are also discussed. Tube thoracostomy, which can be performed with basic surgical skills if attention is paid to potential complications and optimal technique, is described.