Laryngeal Mask Airway insertion with total intravenous anesthesia for transsternal thymectomy in patients with myasthenia gravis: report of 5 cases.

Myasthenia gravis is a chronic autoimmune disease characterized by a reduction of postsynaptic nicotinic acetylcholine receptors at the neuromuscular junction. Most myasthenia gravis patients require thymectomy. Intravenous (IV) anesthetics may be superior to inhalation agents in these patients. The Laryngeal Mask Airway (LMA), when compared with the endotracheal tube, causes less airway resistance, which in turn may lead to a decreased bronchoconstrictive reflex, less atelectasis, and fewer pulmonary infections. We report 5 patients with myasthenia gravis, who underwent transsternal thymectomy with total IV anesthesia and LMA.

Low-molecular-weight heparin for treatment of submassive pulmonary embolism after pneumonectomy.

Pulmonary embolism (PE) after lung resection has a high mortality rate, and it is one of the most severe complications after lung resection. Early diagnosis and treatment are essential. We present a case of severe PE after left pneumonectomy for lung cancer. Computed tomography angiography was useful for confirming the diagnosis of PE. Low-molecular-weight heparin (LMWH) was used to treat the embolism, and the patient was discharged on the seventh day. LMWH is an effective and safe agent for the treatment of PE after pneumonectomy and may reduce the need for surgery. It may be used as an initial procedure. Secondary severe complications, including hemorrhage and subsequent empyema, may be avoided with the use of LMWH.

Management of complicated hydatid cyst of the thorax.

BACKGROUND: Complicated hydatid cyst of the thorax is important to the clinical approaches and treatment methods in hydatid disease. The aim of this study was to evaluate the problems of complicated pulmonary hydatid cyst, including choice of surgical methods, diagnostic clues and to discuss the inherent risks of medical therapy and the delay of surgical treatment in pulmonary hydatid disease. METHODS: Between 2002 and 2006, 40 operations were carried out in 37 patients whose diagnoses were complicated hydatid cyst. The surgical approach was a posterolateral thoracotomy in all patients; a phrenotomy in two patients and a thoracoabdominal approach in one patient and two-stage bilateral thoracotomy in four patients. The preferred surgical treatment procedure was cystotomy and modified capitonnage, which was carried out in 26 patients (70%). Other procedures included a cystotomy in five (14%) and decortication in six (16%) patients. Segmentectomy was carried out in 1 (3%), and wedge resection in four patients (11%). RESULTS: In 25 patients (67.5%), there were single hydatid cysts; whereas 12 patients (32.5%) had multiple cysts. Eleven patients had preoperative hydatid cyst history. Iatrogenic rupture of an intact hydatid cyst occurred in three patients. Extrathoracic involvement was apparent in 10 patients (27%). Intrathoracic but extrapulmonary involvement was apparent in six patients (16%). The morbidity ratio was 5%; there was prolonged air leak and atelectasis in one patient each. The mortality ratio was 3% (one patient). The average hospitalization duration for all patients was 5.7 days (range, 3-17 days). The mean follow up was 18.4 months with no recurrence. CONCLUSION: Complicated hydatid cyst may have different clinical manifestations and may present radiologically as a primary lung tumour. In patients with suspicious lung masses owing to endemic area, history of a hydatid cyst or contralateral or extrathoracic hydatid cyst involvement at the same time should indicate a complicated pulmonary hydatid cyst. Preoperative anthelmintic therapy must be avoided owing to the risk of perforation. Treatment of a complicated hydatid cyst differs from that of an intact hydatid cyst. Anatomic resection may be necessary owing to destroyed lung tissue secondary to suppuration from a hydatid cyst; however, parenchymal preserving surgery is preferable in an uncomplicated hydatid cyst. A modified capitonnage method is recommended for complicated hydatid cyst treatment as it has a low morbidity rate.

Unusual radiologic manifestations of the echinococcus infection in the thorax.

Unusual location and presentation of hydatid cyst disease in the thorax requires careful consideration with respect to clinical approach and therapy. In this pictorial essay, we present imaging findings and describe treatment of thoracic hydatid cysts in patients with lung, mediastinal, chest wall, cardiac, endobronchial, pulmonary artery, and diaphragmatic involvement. A review of the literature is also included.

[Mersilene mesh-methyl methacrylate sandwich graft reconstruction for repair of chest wall defects]. / Toraks duvari defektlerinin onariminda mersilen mes-metil metakrilat sandviç greft kullanimi ile rekonstrüksiyon.

The diameter of the defect after resection exceeds 5 cm especially in primary malignant and metastasis of chest wall tumors and bronchial carcinomas invading chest wall. Reconstruction must be performed in cases in which antero-lateral chest wall and sternum were resected in order to prevent paradoxical respiration caused by chest wall instability and to protect the vital organs from external effects. Eight cases undergoing chest wall resection for varying indications and reconstruction with methyl methacrylate-mersilene mesh (MM-MM) sandwich graft between March 2003 and September 2005 were reviewed. The reconstruction technique of MM-MM sandwich graft was compared with other reconstruction materials. Early and late postoperative mortality and morbidity ratios of the cases that MM-MM sandwich graft performed were compared with the other prosthetic materials in literature. All of the patients were extubated in the early postoperative period. There were no postoperative mortality and morbidity. Mean hospital stay was 9.6 days (range, 5-11 days). Mean follow-up was 9 (range, 3-34 months) months paradoxical respiration was no observed in whole patients during follow-up period. We recommend use of the MM-MM sandwich graft rather than the PTFE graft for large defects of the anterolateral chest wall and sternum for successful prevention of paradoxical respiration. Additionally, the MM-MM provides better cosmetic options, is inexpensive and easy to apply, and offers minimal morbidity.

Comparison of alpha-stat and pH-stat cardiopulmonary bypass in relation to jugular venous oxygen saturation and cerebral glucose-oxygen utilization.

UNLABELLED: Jugular venous oxygen saturation (SJVO(2)) reflects the balance between cerebral blood flow and metabolism. This study was designed to compare the effects of two different acid-base strategies on jugular venous desaturation (SJVO(2) <50%) and cerebral arteriovenous oxygen-glucose use. We performed a prospective, randomized study in 52 patients undergoing cardiopulmonary bypass (CPB) at 27 degrees C with either alpha-stat (n = 26) or pH-stat (n = 26) management. A retrograde internal jugular vein catheter was inserted, and blood samples were obtained at intervals during CPB. There were no differences in preoperative variables between the groups. SJVO(2) was significantly higher in the pH-stat group (at 30 min CPB: 86.2% +/- 6.1% versus 70.6% +/- 9.3%; P < 0.001). The differences in arteriovenous oxygen and glucose were smaller in the pH-stat group (at 30 min CPB: 1.9 +/- 0.82 mL/dL versus 3.98 +/- 1.12 mL/dL; P < 0.001; and 3.67 +/- 2.8 mL/dL versus 10.1 +/- 5.2 mL/dL; P < 0.001, respectively). All episodes of desaturation occurred during rewarming, and the difference in the incidence of desaturation between the two groups was not significant. All patients left the hospital in good condition. Compared with alpha-stat, the pH-stat strategy promotes an increase in SJVO(2) and a decrease in arteriovenous oxygen and arteriovenous glucose differences. These findings indicate an increased cerebral supply with pH-stat; however, this strategy does not eliminate jugular venous desaturation during CPB. IMPLICATIONS: A prospective, randomized study in 52 patients during cardiopulmonary bypass revealed that pH-stat increased jugular venous oxygen saturation and decreased arteriovenous oxygen-glucose differences. There was no difference in the incidence of jugular venous desaturation. These findings suggest an increased cerebral blood flow with no protection against jugular venous desaturation during pH-stat.

The comparison of caudal ketamine, alfentanil and ketamine plus alfentanil administration for postoperative analgesia in children.

BACKGROUND: Our aim was to compare the effect of single dose caudal ketamine, alfentanil or a mixture of both drugs in the treatment of pain after hypospadias repair surgery in children. METHODS: The group comprised 109 boys, ASA I-II, aged 1-9 years, who were undergoing hypospadias repair surgery as day cases. The children were randomly divided into three groups for postoperative analgesia: group 1, only alfentanil (20 microg x kg(-10) was given caudally; group 2, ketamine (0.5 mg x kg(-1)) alone; and group 3, alfentanil (20 microg x kg(-1))-ketamine (0.5 mg x kg(-1)) was given caudally. The analgesic effect of caudal block was evaluated using the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) and sedation was assessed using a five-point sedation score. The first analgesic requirement time and the number of supplementary analgesics required by each child in a 24-h period were also recorded. RESULTS: No statistical differences were found in demographic characteristics, haemodynamic and respiratory parameters, objective pain scores, postoperative sedation scores and duration of surgery among the groups. The median time to first analgesia was significantly shorter in group 1 than in groups 2 and 3 (P=0.009, P=0.001). Significantly more patients in group 1 required additional postoperative analgesia (paracetamol 15 mg x kg(-1)) compared with groups 2 and 3 (P < 0.001). CONCLUSIONS: Caudal administration of ketamine 0.5 mg.kg-1 with or without alfentanil in children produced satisfactory postoperative analgesia without respiratory depression or other side-effects.