[Emergency tracheostomy in patients with postintubation tracheal stenosis; an uncertain and risky practice]

Usually, postintubation tracheal stenosis [PITS] can be diagnosed by history and physical examination. Emergent tracheotomy is performed in some patients who present with severe dyspnea. In our view, dilatation of the stenosis can resolve the patient's acute issues and prevent complications of tracheotomy. In this study, we evaluate the results and complications of emergent tracheotomy compared with dilatation. This retrospective, case-control study performed on patients with postintubation tracheal stenosis in a seven years period. The case group was patients who underwent emergent tracheotomy prior to admission to our center. The control group had not been undergone tracheotomy and the relief of dyspnea was accomplished by rigid bronchoscopy and dilatation. Patients who received elective tracheotomies were excluded from the study. Tracheal resection and anastomosis was performed for all patients who had favorable condition after initial supportive therapy. The variables including length of stenosis, length of resection, duration of hospitalization, subglottic involvement, results of surgery, and unresectability were compared between two groups. Statistical tests were T-test and chi-square. The average follow-up time was 9.8 [1-33 months] in the case group and 10.2 [1-52 months] in the control group. 721 patients [511 male, 210 female] were evaluated, with a mean age of 27.2 years. 104 patients received emergent tracheotomies. Subglottic involvement and unresectability were greater and response to bronchoscopy and dilatation was lower in the case group [P<0.05]. Following factors, age [younger], length of resection and failure in surgery were also higher in the case group, although the difference was not statistically significant. Emergent tracheotomy in these patients in an avoidable procedure which can lead to failure of desired results. In critical cases, severe acute stenosis can be best managed with rigid bronchoscopy and dilatation

Dysphonia and cervicomediastinal mass, very unusual presentation of hydatid cyst

Hydatid disease, still endemic in developing countries, involves the liver and the lungs of the vast majority of cases. We report a very rare presentation of hydatid disease in a 35 year-old man with a cervicomediastinal mass and vocal cord paralysis, suspected of thyroid tumor. Surgery was curative and dysphonia disappeared completely

Solitary fibrous tumor of the pleura: a case report and review of the literature

Solitary fibrous tumor of the pleura [SFTP] is a rare mesenchymal cell tumor that can be benign or malignant. The best treatment of this tumor is a complete surgical resection. We present clinical and histopathologic characteristics of the 4 patients and their outcomes

Pulmonary metastatectomy and survival rate of patients

Although presence of pulmonary metastasis is indicative of disease progression and its untreatable nature, in recent decades, numerous efforts have been made for treatment of these patients by surgical resection of metastatic lesions. The efficacy of this procedure has been variable in various reports and different diseases. This study aimed to evaluate the effect of metastatectomy in survival rate of patients with pulmonary metastases who underwent metastatectomy in Masih Daneshvari hospital. This was a retrospective study and we evaluated medical records of 99 patients suffering pulmonary metastasis who had been referred to our center during 1995-2007; out of which 48 patients who were qualified for metastatectomy underwent this operation. The required qualifications for surgery included: feasibility of resecting all metastatic lesions, tolerance of surgery by the patient, absence of metastatic lesions in organs other than the lungs, and control of primary disease. Information regarding the site of primary lesion and its pathology, time interval between the diagnosis of primary disease and metastasis, surgical morbidity and mortality, form of surgical procedure, type of incision, number of pulmonary metastases and survival rate of patients was collected. Patients were followed up via clinical visits. In case of insufficient clinical visits, we contacted the patient or his/her family and collected the rewired data. Obtained data were analyzed using SPSS software. To assess the patients' survival rate after the operation, Kaplan-Meier test was used. Sixty-seven pulmonary metastatectomies were conducted on 48 patients [31 males and 17 females] in the age range of 16-86 years [mean 40 yrs]. Twenty-five patients had unilateral and 23 had bilateral metastases. Among patients with bilateral metastases, 7 underwent single-phase metastatectomy while 16 underwent two or multi-phase metastatectomy. Surgical incisions were done through the following approaches: in 60 cases through postero-lateral thoracotomy, in 4 cases through mid-sternotomy and in 3 cases through bilateral anterior-transverse thoracotomy along with sternotomy [clamshell]. In 61 cases pulmonary metastatic lesion was removed by wedge resection, in 14 cases by lobectomy and in one case by pneumonectomy. Mean number of resected lesions was 6.7 [range 1 to 59]. Post-operative complications occurred in 10 patients [15%] including pneumothorax in 9 cases and chylothorax in one. No morbidity, mortality or life-threatening complications occurred in any of the patients. The mean survival of patients following metastatectomy was 22 months [range 1 to 128 months] and their 5-year survival was 24.5% Five patients had 5 years [60 months] or more survival. Although the under-study population was not homogenous pathologically, it seems that metastatectomy with acceptable morbidity, increases the survival of patients and in some cases results in their complete recovery

Surgical treatment of complicated pulmonary hydatid cyst

Hydatid disease is caused by an infection with the cestode, Echinococcus granulosus and is endmic in Iran. Medical therapy and surgical management are two main treatments. The purpose of this study is to represent our ten-year experience in surgical management of patients with complicated pulmonary hydatid disease including cysts ruptured into the pleural space or bronchi, multiplicity, hemoptysis, large size cysts and coexistence with liver cysts. Medical records of 109 patients, who underwent surgery for the treatment of pulmonary hydatid disease in Masih Daneshvari Hospital from December 1995 to October 2005, were reviewed. Among these patients, we selected our study group in accordance with the following criteria: 1] Cyst rupture into the pleural space or bronchi, 2] Occupying more than two third of the hemithorax in radiological studies, 3] Multiple cysts, 4] Massive hemoptysis, and 5] Synchronous pulmonary and liver cysts. Among the 109 patients with pulmonary hydatid cyst, 82 patients [59% male and 41% female] met the above mentioned criteria. The mean age of patients was 31.7 years [range 9-80 yrs]. The cyst diameter was determined by radiological imaging. The mean diameter was 6.23 cm, and 13 patients had giant cysts [occupying more than 2/3 width of the hemithorax]. In this study group 55 patients had ruptured hydatid cysts, 29 had multiple cysts, 11 had significant hemoptysis and 15 had synchronous pulmonary and liver cysts. All patients had undergone surgery with or without previous medical therapy. Our procedure of choice was thoracotomy, cystectomy and closure of the bronchial openings before irrigating the cavity with silver nitrate [0.5%] soaked sponge. Pulmonary resection was done in 8 patients due to the irreversible parenchymal damage. Post operative complications occurred in 16 [19%] patients including residual pleural space in 8, broncho-pleural fistula in 2, pleural effusion in 1, pulmonary embolism in 1, osteomyelitis of sternum in 1, laceration of diaphragm in 1, and inability to access the liver hydatid cyst after thoracotomy and post operative pulmonary insufficiency necessitating mechanical ventilation also in 1 patient. One patient died because of sepsis [she had been operated on for combined pulmonary and liver hydatid disease]. In the 1 to 60 months follow up period, 2 recurrences occurred. Although post operative complications occurred in 19% of our patients, all were treated by conservative managements. This rate of complications was acceptable among patients with complicated hydatid disease. Our procedure of choice is draining the cyst; closing all the bronchial openings in the pericyst and leaving the pericyst cavity open into the pleural space

History of thoracic surgery in Iran

The field of thoracic surgery is a postgraduate sub-specialty of general surgery and has developed considerably in Iran during the recent decades. Nowadays, thoracic surgery procedures are performed by specialists who have been trained specifically in this field and the quality of care given is in line with international standards. This paper addresses the history of thoracic surgery in Iran. Data were collected through interview of professors, review of archives and personal albums and data present in the council of medical education. Almost 80 years ago, general surgeons used to perform thoracic surgical procedures. But closed-circuit anesthesia was not prevalent in Iran until 1940 and there was no training available in the country for thoracic surgeons. Antibiotics were not available and surgeons were not acquainted with new methods to evacuate the pleural space [chest tube and under water seal drainage]. The only procedures performed were limited to management of emergencies, trauma and abscess drainage. Surgical intervention for treatment of tuberculosis in some patients was one of the factors responsible for development of this field of surgery. General surgeons trained abroad that came back to Iran were familiar with the principles of thoracic surgery and would perform it. In some army medical centers and some centers affiliated to foreign countries, thoracic surgeries were performed by Iranian or foreign physicians. Professor Yahya Adl used to perform thoracic surgeries and taught it to his residents. In 1951, Dr. Sadegh Ghazi and shortly after, Dr. Anwar Shakki started operations in Bou-Ali and Abo-Hossein Hospitals at the request of the TB charity foundation. They were the pioneers who started to perform TB, lung and thoracic surgeries. They were educated in France. The period of 1951-1961 can be considered as the initiation period of thoracic surgery as a subspecialty in Iran. Afterwards, this field was extended to the Masih Daneshvari, Sorkheh Hesar and army medical centers. In early 1950, cardiac and vascular surgeon graduates from the USA and other countries who had returned home established the field of thoracic surgery at Tehran University and other universities. Thus, official training in this field was started. In 1984, thoracic surgery became a postgraduate sub- specialty field approved by the medical education council. Thus far, over 80 physicians have graduated in this field most of which are working in academic fields throughout the country. Tehran, Shaheed Beheshti and Tabriz Universities of Medical Sciences have departments approved for training thoracic surgery fellows. In many universities and several medical centers, trained surgeons have established thoracic surgery wards and are working in this field

Effect of chest tube suction on air-leak following lung resection

Air-leak is of the common complications of pulmonary resection, yet there is no consensus on its management. Some authors are in the belief that if, after surgery the lung can remain open, absence of suction will quickly stop the air-leak from the chest tube, whereas others believe that using the suction is essential. This study aims to evaluate the role of chest tube suction after surgery. This is a randomized clinical trial performed on 31 patients who underwent different lung surgeries. After surgery, chest tubes of all patients was connected to the suction till the next morning. Afterwards suction was discontinued for 3 hours and chest radiography was obtained. In presence of pneumothorax in chest-x-ray or in cases of airleakage from the chest tube, use or no use of chest tube suction was determined randomly. In 13 out of 31 patients, chest tube suction was used. In these patients, adding the suction had no effect on shortening the duration of air-leak or hospital stay. We also tried to evaluate the probable effective causes of air-leak in these patients. In this regard we did not find any relation between the age, FEV1 and PaO2 before the operation with air- leakage after the surgery. But there was a significant correlation between the rate of air-leakage and PaCO2 before the surgery. Risk of air-leakage on the 7th day after surgery was greater in those patients in whom the degree of air-leakage was higher on the first day. Use of chest tube suction had no effect on controlling the air-leakage. In this study, use of chest tube suction had no effect on shortening the air- leak period after surgery. In our patients, PaCO2 was an important factor in predicting the risk of air-leak from the chest tube

Management of delayed diagnosed esophageal perforation

The esophageal perforation can be fatal unless diagnosed promptly and treated effectively. The high mortality rate related to delayed treatment is due to an inability to effectively close the perforation site to prevent leakage and ongoing sepsis. This study was performed on patients who were referred to three hospitals of Shaheed Beheshti and Tehran Universities of Medical Sciences during two years. All patients admitted in these hospitals with esophageal perforation lasting for more than 24 hours were studied. There were 24 patients [12 males, 12 females] with the mean age of 37.5 yrs. The most frequent symptoms and signs were: Chest and abdominal pain in 11 cases [45.83%], empyema in 11 cases [45.83%], fever in 10 cases [41.66%], pleural effusion in 8 cases [33.33%] and emphysema in 3 cases [12.5%]. The most common causes of esophageal perforation were use of devices during esophagoscopy and foreign bodies in 13 cases [54.17%], iatrogenic trauma in 4 cases [16.67%], Boerhaave's syndrome in 4 cases [16.67%], ingestion of burning chemicals in 2 cases [8.33%] and esophageal cancer in 1 case [4.17%].Four [16.66%] of all patients died while others were discharged with no significant complication in long time. This study was performed on patients referred to university hospitals; therefore, the results are different from those of community. Most of the perforations were due to intraoperative negligence or device manipulation. The outcomes of the whole procedures were good concluding that late diagnosed esophageal perforations can be managed surgically with good results but with a longer period of hospitalization

Suicide attempts as the cause of post intubation airway stenosis [PIAS]

The incidence of suicide attempt has been increasing in recent years. Presenting a group of patients who attempted suicide, underwent ventilatory support and developed postintubation airway stenosis [PIAS] may help us in prevention and better understanding of this complication. Among patients who referred to our center for treatment of PIAS, those who had been intubated for suicide attempt were investigated in a prospective study. Information was entered in a questionnaire and regular follow ups were done in a 15-month period [April 2003 to July 2004]. Among 100 patients with PIAS, 19 enrolled in this study including10 females and 9 males [mean [ +/- SD] age, 25.3 [ +/- 9.96] yrs; ranging from 17 to 56 yrs]. Type of disease and reasons of suicide were categorized by a psychologist as follows: Eleven patients with psychosocial stress along with an immature personality back-ground, 7cases of psychological disorders and one with an unknown cause. Direct causes of committing suicide included family problems in 10 cases, lovesick in 2, addiction in 3, depression in 6 and social problems in 2 cases [some patients mentioned two reasons and one refused to mention the reason]. Mean time of intubation was 14.78 days [3-30 days], and the mean length of stenosis was 35.12 mm [20-50 mm], 8 patients underwent tracheostomy. Three patients were treated with bronchoscopic dilation and 16 underwent laryngotracheal resection and reconstruction. There were 8 cases of recurrence after resection among which 4 were treated by second resection, 2 recovered by bronchoscopic dilation and 2 managed by stenting. This group of patients [study group] was compared with a similar group of patients in whom the causes of intubations were different [control group]. Incidence of postsurgical recurrence [p=0.011] and the length of stenosis [p=0.01] were higher in the study group. In our patients, social problems such as unemployment, illiteracy and singleness were the more frequent causes of suicide compared with psychological disorders. Patients who undergo mechanical ventilation due to suicide and develop PIAS could be treated by tracheal resection and reconstruction; although the incidence of post- surgical recurrence is higher in them compared with the other groups of patients with PIAS

Systemic primary amyloidosis presenting as generalized lymphadenopathy and massive pleural effusion

A 73 year-old man with cough, dyspnea, generalized lymphadenopathy and left sided pleural effusion was admitted with primary impression of lymphoproliferative disorders. The precise evaluation showed systemic primary amyloidosis with the rare presentation of generalized lymphadenopathy and massive pleural effusion without any other organ involvement as the available tests showed