Laparotomy Vs thoractotomy to repair traumatic diahragmatic hernia after blunt trauma

Blunt injuries of the diaphragm are becoming more common with higher automotive speeds and increased use of seat belt restraints. In some cases, the decision about whether to perform thoracotomy or laparotomy to repair the injured diaphragm is difficult. It is the most commonly missed injury after blunt thoaracic injuries. There is a wide range of clinical presentations and a wide range of complications. Successful diagnosis and treatment require a high level of suspicion and early surgical repair. We reviewed our experience in managing these injuries over the last 5 years to choose the proper approach in the injuries. Retrograde study included patients admitted into Suez Canal University Hospitals or Ben Sinai Teaching Hospitals in Hadhramout over the past five years, from 1[st] April 2003 to 31[st] March 2008 that has been diagnosed and treated as having traumatic rupture of the diaphragm and traumatic diaphragmatic hernia. Clinical presentation, diagnosis, associated lesions and management were reviewed. We studied 48 patients, 32 male patients [66.6%] and 16 female patients [33.4%]. The age ranged between 8 and 67 years. There were 8 isolated lesions [16.7%], 20 cases associated with intra-abdominal lesions [41.6%], 8 patients with intra-thoracic injuries [16.7%] and 12 patients with abdominal and thoaracic injuries [25%]. Intra-abdominal associating lesions diagnosed or suspected after ultrasonography in 20 patients indicated laparotomy as the chosen approach to deal with the lesion and reduce the hernia and repair the diaphragm. Intra-thoracic associating lesions indicated thoracotomy in 8 patients to deal with the intra-thoracic lesions, reduce the hernia and repair the diaphragm. In presence of abdominal and thoracic injuries, laparotomy was the chosen approach as long as the thoracic injuries do not indicate intervention e.g. fractured ribs in 4 patients, Lung laceration and fractured ribs were found in 3 cases and lung contusion and fractured ribs in 5 patients. The isolated lesions of traumatic diaphragmatic hernia. In 5 cases, the lesion suspected after chest X-ray and confirmed after insertion of Ryle's tube and were operated upon through thoractotomy, reduction of the hernia indicated widening of the diaphragmatic tear in 3 cases, injury to small bowel happened in two cases and this indicated later laparotomy. In the other 3 patients the lesion was missed and all the three were operated upon through a laparotomy without any intra-abdominal complications. Presence of evident intra-thoracic lesion which indicates direct intervention is the only indication for thoracotomy in such patients; otherwise, laparotomy is the approach with easy repair and minimal post-operative complications

Thoracoscopic sympathectomy as a treatment for palmar hyperhidrosis

Hyperhidrosis can cause significant professional and social handicaps. Thoracic endoscopic sympathectomy has become the surgical technique of choice for treating intractable palmar hyperhidrosis and is usually considered as a simple and safe procedure. A retrospective study was undertaken to determine the effectiveness of this procedure. Between January 2003 and December 2004, 30 consecutive patients were operated on for palmar hyperhidrosis. There were 12 men and 18 women, ranging in age from 18 to 40 years [mean 29 years]. In all cases, the procedure was bilateral. The procedure was performed in one stage in all patients. All patients were seen 1 month and follow-up to one year after the operation. Successful sympathectomies were performed in 100% of the patients; the follow-up was from 1 to 12 months [mean 6 +/- 3.4 months]. There was no recurrence of palmar hyperhidrosis. No Horner's syndrome was reported. No mortality or serious complications were observed, nor the need to convert to thoracotomy. There was compensatory sweating in 6 patients [20%]. Two patients [6.7%] had residual pneumothorax which didn't require drainage. One patient [3.3%] had hemothorax which was minimal and didn't need drainage. Thoracoscopic sympathectomy is a safe and effective method for managing palmar hyperhidrosis

Comparison between posterolateral thoracotomy and vertical axillary thoracotomy regarding nerve impairment and its neurophysiologic implication

The aim of this study is to analyze the degree of intercostal nerve impairment in posterolateral and vertical axillary thoracotomy and verify that the severity of long standing post-thoracotomy pain is related to the degree of nerve damage. This study includes 45 patients operated upon at Cardio-thoracic surgery Department - Suez Canal University over one and a half year-duration [March 2004 through October 2005]: 30 patients for posterolateral thoracotomy and 15 patients for vertical axillary thoracotomy. The needs to relieve the immediate postoperative pain were recorded. The neurophysiologic recordings were performed one month after thoracotomy either posterolateral or vertical axillary to assess the following [1] the presence of superficial abdominal reflexes [mediated in part by the intercostal nerves] [2] the somato-sensory evoked response after electrical stimulation of the surgical scar [3] the electrical thresholds for tactile and pain sensation of the surgical incision. The patients with posterolateral thoracotomy needed opiates to relieve early pain and showed a higher degree of intercostal nerve impairment compared to those produced by the vertical axillary thoracotomy as revealed by the disappearance of the abdominal reflexes, larger reduction in amplitude of the somatosensory evoked potentials and a higher increase of the sensory thresholds to electrical stimulation of both tactile perception and pain. This study is showing the pathophysiologic differences between the two approaches and suggests that the minor long lasting post thoracotomy pain among the vertical axillary thoracotomy patients is partly due to a minor nerve damage. We can also conclude that nerve injury and nerve impairment after PLT arc responsible for the increased needs for narcotic analgesics during the immediate postoperative period as well as the long lasting neuropathic pain later on. So, it is necessary to match specific treatment to the neuropathic pain generating mechanisms

Thoracoscopic biopsy versus ultrasound guided biopsy to diagnose peripheral intrathoracic lesions

Now, thoracoscopy is a well-defined technique of proven value in the investigation, diagnosis and staging of different intrathoracic lesions. Also, ultrasound guided biopsy is a new diagnostic modality in this field. To document the feasibility, safety and reproducibility of thoracoscopic biopsy and compare its results with the ultrasound-guided biopsy to diagnose peripheral intrathoracic lesions. This prospective study included all patients admitted with undiagnosed intrathoracic mass lesion during the period between March 2003 to April 2005. Group A included 45 patients for whom 56 biopsy samples were taken as ultrasound- guided biopsy [11 repeated procedures]. Group B included 30 patients for whom 30 samples were taken thoracoscopically, these included 7 patients from group A who had failed ultrasound-guided biopsy. The results were compared. Group A: 45 patients, 21 males and 24 females the age ranged between 23 and 67 years, mean age was 45+6.14 years ultrasound-guided biopsy was done but repeated for 9 patients then repeated for two of the last group the diagnosis was confirmed in each case by the postoperative pathological examination of the whole resected mass. Ultrasound-guided biopsy showed sensitivity of 57%, it yielded diagnosis in 80% of the patients. The yield increased when more than one attempt was made. Also, pneumothorax occurred in 9% of cases [5 patients], heamoptysis in 3 patients and hemothorax in only one patient. Group B: 30 patients 18 males and 12 females, mean age was 42+3.12 years 7 of them had previously failed ultrasound-guided biopsy. The diagnostic yield was 100%, sensitivity 100% and specificity was 100% as well. The only complication was prolonged air leak [in 2 patients] and one case converted into thoracotomy for excessive bleeding. Thoracoscopy is highly feasible, safe and having a high diagnostic yield. Both the sensitivity and specificity of thoracoscopy are much higher than those of the ultrasound-guided biopsy. Recent technologic advances including specially designed ultrasound needles will allow more precise needle placement and will lead to a higher diagnostic lead when recent equipments become available to us. In most of the cases, both ultrasound-scanning, CT-scanning and thoracoscopy are complementary to each other to diagnose peripheral intrathoracic masses

Neurogenic mediastinal tumours, a ten-year experience

Neurogenic tumours represent 20% of mediastinal tumors in adults and 35% of such tumours in children; as shown in most of previous studies. We reviewed the patients in whom we found surgical mediastinal tumours in our unit from 1[st] May, 1995 through June 2005. The aim is to evaluate management of cases proved to be neurogenic mediastinal tumours. During the last ten years, we admitted into our unit 132 patients with surgical mediastinal tumours. Full investigations including CT-scanning with contrast and CT- guided biopsy or ultrasound guided biopsy were performed. Thirty-three patients were proved to have neurogenic tumours. From these 132 patients with surgically-treatable mediastinal masses, we found 33 cases of neurogenic pathology [25% are neurogenic tumours]. All neurogenic tumours were in the posterior mediastinum, and represent 75% of all posterior mediastinal masses. There were 29 adults and 6 children [aged <16 years] Mean age was 36.4 years ranging from 5 to 67 years. Nineteen patients were females and only 14 were males. At operation, 27 had complete surgical resection while six patients had only biopsy. We did not find any dumbbell tumour among our patients. After pathological examination there were 14 benign schwannomas, 3 neurofibromas 2 ganglioneuromas, 4 malignant schwannomas, 3 neurobalstomas and one ganglioneuroblastoma. All patients with malignant lesions were from North Sinai. In our series, neurogenic tumours represented 25% of all mediastinal tumours, 39.4% in children and 21.3% in adults included in the study [132 patients]. Benign tumours had an excellent prognosis after resection and a five-year-follow up. In our series, malignant ones represented 22% of all neurogenic masses. Prognosis of these malignant tumours in children was better than in adults. The higher the grade of malignancy the poorer is the prognosis even after radio and/or chemotherapy. Neurogenic tumours are more frequent in females. They should be treated early to get a better prognosis. Incidence of tumours is markedly higher among patients from North Sinai. High resolution CT and/or US studies were quite enough for accurate diagnosis. MRI studies were not essential to diagnose any of our cases

Effect of postero-lateral and vertical axillary thoracotomy on both pulmonary function and pulmonary complications after these thoracotomies

The aim of this study is to compare between postero-laleral [PLT] and vertical axillary thoracotomy [VAT]-[a muscle sparing thoracotomy] on both pulmonary functions and Pulmonary complications after these thoracotomies. The use of dynamic pulmonary volumes such as the timed VC, FEV1 and maximal breathing capacity [MBC] provides an index of obstructive air way disease [1]. The FEV1 is usually related to the total exhaled vital capacity [VC]. Immediate post-operative blood gases can help to assess the respiratory mechanisms and tolerance to pain [2]. This study includes 45 patients operated upon at Cardio-thoracic Surgery Department, Suez Canal University Hospitals over two years [March, 2003 though April, 2005]. Thirty patients for PLT [group I], Fifteen patients for VAT group II] preoperative and postoperative pulmonary functions, were compared. Also, all postoperative pulmonary complications were recorded and compared. Standard posterolateral thoracotomy [PLT] was performed in 30 patients [17 males and 13 females], mean age about 48.4 +/- 11.6 years and mean body weight 55.6 +/- 6.4kg. Vertical axillary thoracotomy [VAT] begins below axillary hair line performed in 15 patients [group B]: 6 males and 9 females with mean age 58.8 +/- 11.4 years and mean body weight [52.8 +/- 7.9kg]. FEV1/FVC% showed reduction varied between 6-11% among group I patients; whereas the reduction in FEV1% did not exceed 2-4% among group II patients which is statistically significant [p<0.005]. Blood gases showed better results even on room air in patients with VAT. CO[2] retention and PH <7.4 and lower O[2] contents were proved in most of the patients with PLT incisions [18 out of the 30 patients in this group i.e. 63.3%] but only in 3 patients among patients with VAT [20%] [p<.005]. Also, postoperative pulmonary complications: Atelectasis [15.6% in group I versus 3% in group II] and persistent air leak [10% vs 0%] and prolonged stay in hospital were statistically significant in group I patients; and insignificant in group II patient. VAT [muscle-sparing thoracotomy] resulted in improvement in pulmonary functions that require forced expiration in which accessory muscles of respiration of chest wall are used as FVC and FEV1 and FEV1% as well as improved blood gases after surgery. This improvement is statistically significant when compared with the marked reduction shown after PLT. Also, we report reduced incidence of postoperative pulmonary complications and shorter stay in hospital after VAT compared to those after PLT