Acute effects of lobectomy on right ventricular ejection fraction and mixed venous oxygen saturation

Traditional methods of assessing the operative risk for lung resection provide only a modest ability to predict postoperative morbidity and mortality. The aim of this study was to evaluate the effect of lobectomy on pulmonary hemodynamic and gas exchange variables using the RV thermodilution ejection fraction/oximetric catheter. We evaluated the acute postoperative effects of lung resection on hemodynamic and gas exchange parameters in 30 patients. Anesthesia was induced with thiopentone sodium and maintained with midazolam, fentanyl and pipecuronium. Intubation was performed with a double-lumen, left-sided endobronchial tube for one lung ventilation. The hemodynamic and gas exchange parameters were recorded before and after induction of anesthesia, and two hours after lung resection. These parameters were also recorded after the classification of the patients according to the underlying lung pathology. Lobectomy was associated with significant hemodynamic changes and good maintenance of gas exchange variables. SVI, LVSWI and RVEF were significantly decreased in the early postoperative period after lung resection. MPAP, COP, CI, SVRI, PVRI, RVSWI, and RVEDVI showed no significant changes during the perioperative period. SVO2 showed a significant increase after lung resection when compared with preinduction values, while VO2 significantly decreased. SaO2, a-A PO2, QS-QT, DO2, and O2ER showed no significant changes during the perioperative period. We conclude that in the acute post-resection period [up to 2 hours postoperatively] there is right and left ventricular dysfunction with good maintenance of gas exchange

Emergent thoracotomy in congenital malformations of the lung experience in 32 cases

Background: congenital anomalies of the lung are rare disorders that can present by life threatening emergency which may need emergent thoracotomy

Aim: to evaluate our methods of investigations and emergent management of these life threatening problems

Patients and Methods: this study represents the experience of Cardio Thoracic Surgery Department in collaboration with General Surgery Department, Mansoura University Hospital, Mansoura, Egypt on 32 cases who needed emergent thoracotomy for different congenital lung anomalies. Thirty two Consecutive patients had emergent operations from January 1996 until December 2001

Results: eighteen patients had tension lung cysts, 11 patients had congenital lobar over inflation, 2 patients had sequestrated segment, and one patient had congenital arteriovenous malformation. There were 14 males and 18 females, the age ranged from 3 days up to 16 years [mean age4+/-4.2y]. Patients less than 2 years presented with dyspnea, tachypnea, cyanosis, and respiratory distress, while the older patients presented with chest pain, hemoptysis. Plain X-ray chest was sufficient for the diagnosis in 26 patients [81.25%], while CT chest was done in 23 patients [71.8%], bronchoscopy was also done in 6 patients [18.75 %] for exclusion of foreign body inhalation. Curative surgery was achieved by 28 lobectomies, 3 bilobectomies, and in one case by cyst enucleation. The complications were in the form of postoperative pneumonia, atelectasis, air leak and empyema in 14.5% of cases which managed easily. Infants and children tolerate lobectomy extremely well, with compensatory lung growth, so that total lung volume and gas exchange capacity returns to normal during somatic maturation

Conclusion : it is concluded from this study that these congenital lung malformations may cause respiratory distress and hemoptysis and need emergent thoracotomy which is curative. X-ray chest and CT scan are sufficient for accurate diagnosis. Emergent surgery is safe and curative in those patients as infants and children tolerate lung resection very well with compensatory lung growth during somatic maturation

Prosthetic valve endocarditis

Background: prosthetic valve endocarditis [PVE] remains a serious complication of cardiac valve replacement. Patients with valve replacement are at constant risk of 0.6-1% per patient-year for PVE. The mortality is high despite major advances in the treatment of infective endocarditis, which includes more effective antimicrobial therapy and more aggressive surgical procedures

Aim of the work: this study is directed to evaluate patients with prosthetic valve endocarditis managed at the Cardiothoracic Surgery Department, Mansoura University. Evaluation included the mode of presentation, methods of diagnosis and results of different management modalities

Patients and Methods: this is a retrospective study. Between 1994 and 2000, 19 patients were admitted at the Department of Cardiothoracic Surgery, Faculty of Medicine, and Mansoura University for suspected prosthetic valve endocarditis [PVE]. All of the patients have been operated on before in the same department. Retrospective analysis of the patient's charts was performed

Results: the mean age of the patients was 26+/-5.1 years [range 17-41 years] and the male to female ratio was 2:1. Eighteen patients [94.74%] had mechanical valve replacement using bileaflet valves and only one patient [5%] had mitral valve repair using prosthetic ring. Of the 18 patients who had received single valve prosthesis, 8 [42.11%] underwent mitral valve replacement, 6. [31.38%] aortic valve replacement, 4 patients [20.05%] had both aortic and mitral valves replaced. In this study, four patients [21.05%] treated medically using9 antibiotics and supportive medical treatment for heart failure. Fifteen patients [78.9%] required valve medical treatment including antibiotic and supportive treatment of average 15 days. The most common indication for surgery was congestive heart failure caused by paravalvular leakage due to the endocarditis. Paravalvular leak involved more than 50% of the valve circumference with prosthesis dehiscence in 2 patients. In 2 patients, there was persistent fever with refractory sepsis and one patient had septic embolism. The mean aortic cross clamp time was 70+/-14.1 minutes [Interval 55-150 minutes]. The mean cardiopulmonary bypass time was 165+/-26.1 minutes [Interval 100-230 minutes]. The mortality in the medically managed patients was 75% [3 patients] compared to 33.3% [3 patients] in the surgically treated group

Conclusion: 1. PVE remains a surgical challenge, but in order to optimize surgical results, early diagnosis and aggressive medical theraou should go hand-in-hand with Carly surgical intervention especially in those patients known to have a poor prognosis for medical cure and who are at risk for surgical morbidity and mortality. 2. Early reoperation, extensive tis sue debridement with annular reconstruction, could improve the results of the treatment of PVE, but strict prevention measures of intraoperative contamination during valve replacement remains the optimal goal to de crease the incidence and dismal outcome of PVE

Serious chest trauma in children requiring emergency thoracotomy

Background: pediatric trauma remains a major health and social problem. Thoracic injuries are the second leading cause of death in children

Aim of the work: to evaluate our experience in diagnosis and management of serious chest trauma in children either blunt or penetrating which required emergency thoracotomy

Patients and methods: this is a retrospective study of all emergency thoracotomies performed for pediatric patients at Mansoura University Emergency Hospital [MUEH] from January 1997 to December 2002. We reviewed the hospital charts of all patients admitted with the diagnosis of chest injuries either blunt or penetrating injury and selected cases needed emergency thoracotomy. Of the pediatric group, only 50 patients [5%] had serious chest injury, either blunt or penetrating and required emergency thoracotomy were included in this study. Hospital charts of this group of patients were reviewed and classified according to the mechanism of trauma into two groups: Group A: Patients with blunt thoracic trauma; 26 patients [52 %]. Group B Patients with penetrating thoracic trauma; 24 patients [48%]

Results: in the blunt group, 20 patients [76.9%] were males and 6 patients [23.1%] were females, with age ranged from 1 to 16 years [mean 10.0+/-6.4]. In penetrating group, 20 patients [83.3%] were males and 4 patients [16.7 %] were females, with age ranged from 6 to 17 years [mean 12.6+/- 3.4]. In the blunt group, the mechanism of injury was: road traffic accidents in 18 patients [69.26] and falling from height in 8 patients [30.8%]. In the penetrating group, the mechanism of injury was: stab injury in 17 patients [70.8%], gunshot injury in 2 patients [8.4%], 4 patients [16.7%] were victims of iatrogenic trauma and one patient [4.2%] was involved in explosion injury. In both groups the most common side of injury was the left side 29 patients [58 %]. Fifteen patients [57.3%] were in the blunt group and 14 patients [58.3] were in the penetrating group. The pediatric trauma score [PTS] of all children was calculated, it was found that 7 patients [26.9%] of the blunt group and 8 patients [33.3%] of the penetrating group had PTS

Conclusion: from this study concludes that: *A high survival rate can be achieved if emergency thoracotomy, when indicated, is done as long as the patients shows vital signs on admission. *Excellent results are predicted when the surgical interference is performed within the first 2 hours of injury. The emergency thoracotomy could be done in the operating room or in the emergency room provided that the good monitoring and ventilation is available, then patients can be transferred after resuscitation to the operating room for definitive repair of the injuries

Effect of near-total thyroidectomy on thyroid orbitopathy due to toxic goiter

Background: the major determinant of postoperative morbidity and mortality after pulmonary resection is the functional status of the cardiac and pulmonary systems. Right ventricular [RV] thermodilution ejection fraction/oximeteric catheter has been recently proposed as a new technique to evaluate the pulmonary hemodynamics and gas exchange variables in lung resection

Aim of the work: the aim of this study was to evaluate the effect of lobectomy on pulmonary hemodynamics and gas exchange variables using the RV thermodilution ejection fraction/oximeteric catheter and its possible effects on early morbidity and mortality

Patients and methods: we evaluated the acute postoperative effects of lung resection on hemodynamic and gas exchange parameters in thirty patients using the RV thermodilution ejection fraction/oximeteric catheter. Anesthesia was induced with thiopentone sodium and maintained with midazolam, fentanyl and pipecuronium. Intubation was performed with double-lumen, left-sided endobronchial tube for one lung ventilation. The hemodynamic and gas exchange parameters were recorded before and after induction of anesthesia, and two hours after lung resection

Results: lobectomy was associated with significant hemodynamic changes and good maintenance of gas exchange variables. SVI, LVSWI and RVEF were significantly decreased in the early postoperative period after lung resection. MPAP, COP, CI, SVRI, PVRI, RVSWI, and RVEDVI showed no significant changes during perioperative period. Svo2 showed a significant increase after lung resection when compared with preinduction values, while Vo2 significantly decreased. Sao2, a-A Po2., QS- QT, Do2, and Og ER showed no significant changes during perioperative period. No operative mortality is encountered in this study. Post-operative supraventricular arrhythmias were recorded in five patients [16.7%] which were hemodynamically well tolerated and did not correlate with the perioperative changes in the hemodynamics or gas exchange variables

Conclusion: we can conclude that the acute post resection period [up to 2 hours postoperatively] revealed right and left ventricular dysfunction with good maintenance of gas exchange. Despite these changes, lobectomy is well tolerated with minimal morbidity and mortality

Laryngo-tracheal obstruction: results of surgical technique and role of virtual endoscopy in patient evaluation

Introduction: upper airway obstruction is a continuous challenge in diagnosis especially if surgical intervention is required. [1-2-3-4-5] Virtual laryngoscopy [VL] is a technique for creating computer simulations of anatomy from radiological image data and viewing those simulations in a way that is analogous to conventional endoscope.[6]

Aim of the work: the aim of this work was to evaluate the results of surgical reconstruction and to compare the findings with virtual laryngoscopy [VL] and conventional endoscopy in diagnosis of upper air way obstruction

Patients and methods: a prospective study was done at Mansoura University Hospitals at Departments of Otolaryngology and Cardiothoracic surgery, on thirty two patients with an age range of 14-72 years

Results: patients presented with upper airway obstruction, 15 cases of laryngeotracheal trauma, advanced laryngeal carcinoma [10 patients], 2patients of cervical tracheal carcinoma, and granulomatous lesions [5 patients]. Fiber optic and rigid endoscopy were attempted in all patients. Biopsy was done for 28 patients to confirm diagnosis. Spiral CT was performed with slice thickness 2 mm, pitch 1.2mm, and reconstruction .interval 1.5mm. CT data was transferred to workstation software to analyze both ante-grade and retrograde end luminal VL with conventional endoscopy and operative findings. Patients presented with cancer and trauma were operated for laryngectomy and laryngotrache0-plasty. Rigid endoscopy showed upper airway obstruction in 8 patient's trans glottis carcinoma [65%], 1 patients in granulomatous lesions [18%], and 3 [20%] cases of trauma with total success rate 41%. VL showed all luminal obstruction. Only three cases the narrowed segment length was less than operative measurement with total accuracy [94%]. Operation was done for traumatic and cancer patients, comparing the rustles of operative finding and VL

Conclusion: we conclude that high resolution and multiple image of VL are depicting the intraluminal and transmural extent of laryngeal disease non- invasively especially in traumatic causes. Surgical repair is a challenging procedure, however, it could be done with a good results and minimal morbidity and mortality. The mobilization of the trachea and larynx is essential step for closure sutures without tension is highly important. The usage of neck collar in the opposite manner is useful to prevent patient from neck hyperextension and disruption of tracheal sutures