Surgical management of descending necrotizing mediastinitis: strategy for thoracic interference

BACKGROUND

The present descriptive study shares the overall experience of treating all these patients where different surgical process was adopted depending on the treatment required after carefully evaluating the risk factors and comorbidities.

METHODS

The present study was conducted at the Department of Thoracic Surgery, Choray Hospital, Vietnam between the period of 2010 to 2020. We have treated 95 patients altogether in this duration.

RESULTS

We were able to save most of the patients by applying thoracotomy and thoracic irrigation for most of the patients based on the observed indications that were identified immediately after the compulsory standard cervicotomy. The indication for thoracic interference was considered when the infection was deeply spread into the mediastinum and cannot get out through cervicotomy, although the most effective method of drainage was applied.

CONCLUSION

Our statistical investigation of the patient data suggested the possible association and influence of comorbidity such as diabetes. Therefore, we recommend that in specific cases thoracotomy along with thoracic irrigation and repetitive surgical draining could be a better option to reduce the infection and the mortality rate.

TRIAL REGISTRATION

Retrospectively registered.

Comparison of In-Hospital Outcomes of Surgical Stabilization of Rib Fractures with Nonsurgical Management: A Multicenter, Prospective, Cohort Study

Background

Evidence for the efficacy of surgical stabilization of rib fractures in patients with rib fractures is controversial.

Objective

We aim to compare the clinical outcomes of surgical rib fixation for rib fracture with non-operative treatment.

Methods

Our institutional database from three general hospitals (Viet Duc Hospital, Viet Tiep Friendship Hospital & Cho Ray Hospital) was queried to identify patients with flail chest treated with locked plate fixation between December 2021 and February 2023. A medical record review for demographic, injury, hospital, and surgical data was also retrospectively performed for all patients. Characteristics and outcomes of the patients receiving the surgical rib fixation for rib fracture were compared with those without surgery.

Results

A total of 166 patients with thoracic trauma were included. The majority of patients were male, and the age range was from 18 to 80 years old, with a mean age of 51.6 years. 52 (31.3%) underwent surgical stabilization of rib fractures (SSRF). The highest combined injuries were limb injuries, followed by traumatic brain injury, and maxillofacial trauma. While 1 patient died in the non-surgical group, there was no significant difference in the mortality between the two groups. The surgical group had a slightly shorter hospital stay than the non-surgical group (8.6 days vs. 10.0 days, p-value: 0.038). SSRF group tended toward a lower incidence of pneumonia compared to the non-surgical group (SSRF: 3.8% vs. non-surgical: 7%), but this difference was not statistically significant (p-value: 0.426). SSRF group also had a lower incidence of tracheostomy than the non-operative group (SSRF: 0% vs. non-surgical: 1.8%, p-value: 0.337).

Conclusion

Operative fixation of a rib fracture in trauma patients resulted in a lower incidence of pneumonia, fewer days of mechanical ventilation, and a shorter hospital stay compared to non-operative treatment group.

Robotic video-assisted thoracoscopic surgery using multiport triangular trocar configuration: initial experience at a single center

Background

Recent developments in robotic technology have brought significant changes in robotic video-assisted thoracoscopic surgery (r-VATS) worldwide, particularly including the treatment in the thorax for the mediastinal, esophagus, and pulmonary lesions. Currently, there are only a few reports describing the procedural experience and outcomes with r-VATS. The objective of this study is to provide our initial experience using r-VATS at a single center, with specific attention to safety, efficacy, and procedural details.

Methods

We retrospectively reviewed patients who underwent a newly modified r-VATS procedure for various surgical operations at the thoracic department of our hospital, from July 2018 to January 2020. Multiport trocars were placed in the classic triangular arrangement as in conventional VATS (c-VATS) but with modifications based on the type of surgery. The peri- and postoperative outcomes such as duration of surgery, complications, and duration of hospital stay for these patients were reported.

Results

Overall, 142 patients underwent r-VATS for lobectomy (66), wedge resection (15), thymectomy (22), mediastinal tumor resection (30), pneumonectomy (4), transthoracic esophagectomy (1), esophageal tumor resection or esophageal diverticulum repair (2), diaphragm plication (1), and mediastinal tumor resection plus thymectomy (1). For the entire cohort, the median operative time was 110 min, and the median length of hospital stay was 5 days. Conversion to open thoracic surgery was reported only in a total of 3 (2.1%) patients of pneumonectomy (1.4%) and mediastinal tumor resection (0.70%). All our patients were managed successfully with no postoperative complications and mortality.

Conclusion

Our method of r-VATS was found to be safe and effective and may be applied to different surgical operations. Adequate and proper training of thoracic surgeons is immediately needed for the transition from c-VATS to r-VATS. The utility and advantages of triangular trocar configuration for r-VATS require further refinement and research before it can be routinely adopted in clinical practice.

Trial registration

Retrospectively registered.

Surgical repair for post-tuberculosis tracheobronchial stenosis

AIM

Post-tuberculosis tracheobronchial stenosis is rare but one of the most dangerous complications of tracheobronchial tuberculosis. Balloon dilatation, stent insertion, laser photoresection, argon plasma coagulation, and cryotherapy are some of the initial treatments recommended for mild to moderate cases. Here, we report a case series of patients who underwent segmental resection and end-to-end anastomosis for bronchial stenosis and a sliding technique for severe and long-segment tracheal stenosis.

METHODS

We retrospectively reviewed the medical records of patients with post-tuberculosis tracheobronchial stenosis operated on in our thoracic surgery department. Of the 7 cases that were treated, two had severe tracheal stenosis stretching over 50% of the tracheal length, one was operated on using resection and end-to-end anastomosis, and the other had sliding tracheoplasty. The other 5 cases of bronchial stem stenosis were treated with segmental resection and end-to-end anastomosis.

RESULTS

All five patients with bronchial stenosis had a good outcome; the ipsilateral lung was well ventilated and respiratory function was good. One patient with tracheal stenosis, treated with segmental resection and end-to-end anastomosis, died after the surgery, and the other patient, treated with slide tracheoplasty, had a good recovery.

CONCLUSION

The treatment plan for patients with post-tuberculosis tracheobronchial stenosis should be on a patient-by-patient basis. Sliding tracheoplasty can be a treatment option in patients with long-segment tracheal stenosis.

Pectus excavatum repair using bridge fixation system

Background

The stability of the pectus bar is an important determinant of the success of pectus excavatum repair surgery. In practice, several different types of fixation method are in use for stabilizing pectus bars. The aim of this study was to compare the performance of the bridge fixation system with previous fixation systems for stabilizing pectus bars.

Methods

We performed a retrospective review of 1760 pectus excavatum repair cases conducted in the Thoracic Department of Choray Hospital and its satellite hospitals, between 2007 and 2017. We compared the results of 560 patients who had the bridge fixation system with the previous 1200 patients who had other fixation techniques.

Results

The bridge fixation system with 2 bars in 560 patients gave better results in terms of bar stabilization, operative time, and postoperative complications, compared to the previous 1200 patients who had other stabilization techniques. The average skin-to-skin surgery time using the bridge fixation system was 55 min. Of the 560 cases, only one patient showed trivial one bar dislocation, and one had a postoperative complication (pneumothorax).

Conclusions

We found the bridge fixation system to be superior not only in terms of stabilizing the bars but also for minimizing the time of surgery and postoperative complications, compared to other fixation systems. The bridge fixation system with 2 bars showed excellent results. Use of 3 bars is not necessary. One bar was used in the other fixation techniques and the results were found to be inferior compared to those using 2 bars.

Surgical management of esophageal perforation: role of primary closure

Objective

Esophageal perforation is a life-threatening condition associated with high mortality and morbidity. Ambiguous clinical presentation is one of the most common causes of delayed and difficult diagnosis of esophageal perforation. In this retrospective single-center study, we reviewed the outcome of primary closure in patients with esophageal perforation between 2009 and 2017.

Methods

The data of 65 patients attending our department of thoracic surgery (from 2009 to 2017) for esophageal perforation were reviewed. Primary repair was attempted in 63 patients irrespective of the site of perforation and time interval between injury and hospital admission. In intrathoracic lesions, continuous mediastinal and pleural irrigation was undertaken, whereas in cervical perforations, gauze packing and local irrigation were performed. Jejunotomy was carried out in patients with inadequate healing.

Results

Of the 65 patients, 63 underwent primary closure and 2 were left to heal spontaneously. The majority of patients ( n = 44) had an esophageal perforation at the thoracic level, and only one was admitted early (<24 h after injury). Among the 63 patients managed with primary closure, 55 had satisfactory healing with one surgery. Healing was delayed in the other 10 patients. No mortality was reported.

Conclusions

Esophageal perforation can be well managed by primary closure, irrespective of the time interval between injury and hospital admission and the site of perforation. Conservative management might lead to an increased rate of complications such as empyema or necrotizing mediastinitis, and increased morbidity and mortality.

Comparative contractile effects of halothane and sevoflurane in rat aorta

BACKGROUND

Volatile anesthetic agents have been shown to have contractile effects in vascular tissues during specific conditions. This study compared contractile effects of halothane and sevoflurane in rat aorta treated with verapamil. This study also tried to elucidate the mechanism of the contraction.

METHODS

Endothelium-denuded rat thoracic aorta was used for recording of isometric tension and measurement of influx of 45Ca2+. All experiments were performed in the presence of verapamil. In recording of tension, rings were precontracted with a submaximum dose of phenylephrine, followed by exposure to halothane or sevoflurane. For measurement of influx of 45Ca2+, rat aortic strips were exposed to phenylephrine and then to additional halothane or sevoflurane. Influx of Ca2+ was estimated by incubating the strips in 45Ca2+-labeled solution for 2 min.

RESULTS

Halothane (0.5-4.0%) induced contraction in a dose-dependent manner, whereas sevoflurane (1-4%) had no effect on tension. Influx of 45Ca2+ was strongly enhanced by halothane at 1% and 2%, but only slightly at 4%, and was not affected by 1-4% sevoflurane. SK&F 96365, a blocker of voltage-independent Ca2+ channels, abolished contraction and influx of 45Ca2+ by 1% halothane. Depletion of Ca2+ from the sarcoplasmic reticulum with ryanodine or thapsigargin reduced the contraction induced by halothane at 4% but not that at 1% and 2%.

CONCLUSION

Halothane is suggested to cause contraction by enhancing influx of Ca2+ via voltage-independent Ca2+ channels at concentrations up to 2% and by inducing release of Ca2+ at 4%. Sevoflurane (1-4%) is devoid of these contractile effects.

Effects of isoflurane on receptor-operated Ca2+ channels in rat aortic smooth muscle

We have investigated the effects of isoflurane on receptor-operated Ca2+ channels (ROC) in vascular smooth muscle. In isolated rat thoracic aortic rings denuded of endothelium, the effects of isoflurane on phenylephrine-induced contraction and Ca2+ influx were evaluated in the presence of supramaximal doses of nifedipine or verapamil. Under isometric tension recording, the aortic rings were precontracted by phenylephrine 300 nmol litre-1 and exposed to 1.2%, 2.3% or 3.5% isoflurane. Phenylephrine-induced precontraction was enhanced with 2.3% isoflurane by mean 8.1 (SD 9.3)% (P < 0.05 vs 0% isoflurane). The constrictor effect of 2.3% isoflurane was not inhibited by depletion of intracellular Ca2+ stores with ryanodine 20 mumol litre-1, but was abolished in a Ca(2+)-free solution or by SK&F 96,365 30 mumol litre-1, an ROC blocker. Isoflurane-induced contraction was accompanied by increased intracellular free Ca2+ concentration, monitored using fura PE3. Unidirectional 45Ca2+ influx measurement in phenylephrine-stimulated aortic strips revealed that the mean amount of Ca2+ influx was significantly (P < 0.05) enhanced by 1.2% and 2.3% isoflurane, which were 117.1% and 119.7% of control values, respectively. Our results strongly suggest that isoflurane enhanced Ca2+ influx through ROC that had been submaximally activated by phenylephrine.

Suppression of acetylcholine-induced relaxation by local anesthetics and vascular NO-cyclic GMP system

BACKGROUND

Local anesthetics have been demonstrated to attenuate acetylcholine-induced relaxation of vascular smooth muscle, but the mechanism responsible has not been elucidated. The present study was undertaken to ascertain whether this effect of local anesthetics is due to suppression of the vascular nitric oxide (NO)-cyclic GMP (cGMP) system.

METHODS

Isolated rat aortae were cut into helical strips and mounted in bathing solution to measure isometric tension changes. They were precontracted with phenylephrine (0.3 microM) then exposed to cumulative concentrations of relaxants including acetylcholine, sodium nitroprusside (SNP) and papaverine, in the absence or presence of local anesthetics. Aortae for cGMP measurements were cut longitudinally into pairs of strips and bathed in the solution without tension. In the absence or presence of anesthetics, they were stimulated with acetylcholine or SNP, and the cGMP content of each strip was radioimmunoassayed.

RESULTS

Acetylcholine-induced, endothelium-dependent relaxation of phenylephrine-precontracted aortae was attenuated by lidocaine (30-300 microM), tetracaine (10-30 microM), bupivacaine (10-100 microM) and ropivacaine (30-100 microM). SNP-induced relaxation was attenuated by lidocaine (300 microM), tetracaine (30 microM), bupivacaine (10-100 microM) and ropivacaine (30-100 microM). Papaverine-induced relaxation was attenuated by lidocaine (300 microM), bupivacaine (30-100 microM) and ropivacaine (30-100 microM), and augmented by tetracaine (30 microM). Cyclic GMP levels in acetylcholine-stimulated aortae were reduced significantly by lidocaine (300 microM), tetracaine (100 microM) and bupivacaine (300 microM) treatment, but not by ropivacaine (300 microM). SNP-stimulated cGMP levels were reduced by tetracaine (100 microM) but not by any other anesthetics at the concentrations tested.

CONCLUSION

We conclude that lidocaine, tetracaine and bupivacaine suppress acetylcholine-stimulated formation of cGMP. However, the attenuation of acetylcholine-induced relaxation by local anesthetics is not totally ascribable to reduced cGMP levels.