Systematic review of spontaneous pneumomediastinum: a survey of 22 years' data.

OBJECTIVE: To describe and clarify management protocols in relation to spontaneous pneumomediastinum, and try to integrate criteria on this subject. BACKGROUND: Thoracic physicians are faced with patients who present with gas in the mediastinum, frequently without an obvious etiologic factor. Published material contains heterogeneous information from which different conclusions can be drawn. METHODS: In a Medline search from 1990 to 2012, we collected data on mortality, morbidity, signs, symptoms, etiologic factors, and diagnostic methods. Standardized mean differences were calculated. RESULTS: We identified 600 patients in 27 papers with series of >5 patients without precipitating or etiologic factors previous to the clinical presentation, but athletic activity, drug abuse, and history of asthma played an apparent role in the disease process. Most patients complained of thoracic pain and dyspnea, with subcutaneous emphysema and Hamman's sign. The most common complication was tension pneumothorax. Morbidity was seen in 2.8%; no mortality has been reported so far. CONCLUSION: Spontaneous pneumomediastinum is a rare disease with a benign course, which should be treated conservatively unless a complication mandates an invasive procedure. An algorithm for diagnosis and treatment is offered, based on the available evidence.

Descending necrotizing mediastinitis below the tracheal carina.

BACKGROUND: Descending necrotizing mediastinitis is a dreadful disease with a high mortality rate, particularly when below the tracheal carina. This study describes the epidemiologic, clinical, and paraclinical features of patients treated for this condition. METHODS: We performed a single-center retrospective descriptive review of 60 patients with descending necrotizing mediastinitis below the tracheal carina, who were treated during a 7-year period, the largest study in the last 50 years. Demographic, clinical, paraclinical, and therapeutic variables were analyzed. RESULTS: 43 (71.7%) patients were male. The mean age was 41.2 ± 14.7 years. Mean hospital length of stay was 25.0 ± 19.8 days. Comorbidities were present in 46.7% of patients, diabetes mellitus being the most common. Odontogenic infections (45%) were the most frequent source of descending necrotizing mediastinitis. Cultures showed Gram-negative bacilli in 68.3%, Gram-positive cocci in 38.3%, and fungi in 6.7%. Mortality was 35% (21 patients); risk factors for mortality were age (>35 years), diabetes mellitus among other comorbidities, and associated complications. CONCLUSIONS: In this low socioeconomic status patient population, descending necrotizing mediastinitis below the carina causes high morbidity and mortality, the latter particularly associated with age, complications, diabetes mellitus and other comorbidities.

Descending necrotizing mediastinitis associated with spinal cord abscess.

A 58-year-old man with a history of Ludwig's angina was admitted with a spinal cord abscess at the level of C2-T1 and associated osteomyelitic destruction of vertebral bodies, spinal cord compression, and secondary quadriparesis, followed by descending mediastinitis. A right posterolateral thoracotomy and a cervicotomy drained purulent exudates. A tracheostomy was performed, and the patient was discharged after 84 days.

Mediastinal drainage in descending necrotizing mediastinitis.

Descending necrotizing mediastinitis has been thoroughly described in the past, but we could not find a detailed description of the technique to perform adequate drainage and lavage of all the mediastinal and thoracic spaces. We describe the procedure as we perform it, emphasizing the sites for incision and proper drainage of all the mediastinal compartments and the contralateral thoracic cavity.

Descending necrotizing mediastinitis and sternoclavicular joint osteomyelitis.

Descending necrotizing mediastinitis is usually associated with cervical or odontogenic infections. We describe a patient with blunt trauma to the chest 2 years earlier, and a slowly developing chest wall hematoma 18 months prior to admission, complicated by chronic sternoclavicular joint osteomyelitis, eventually leading to descending mediastinitis. Thoracotomy with drainage of the mediastinal spaces and multiple procedures for the sternoclavicular joint infection were successful. The rarity of this association and undefined optimal management prompted this report.

Descending necrotizing mediastinitis and thoracic cellulitis due to varicella.

A 22-year-old man with varicella had associated cervical enlargement, right upper thoracic anterior and suprascapular cellulitis, and mediastinitis. A tracheostomy, right posterolateral thoracotomy, cervicotomy, and upper thoracic fasciotomy were performed 14 h after admission, draining purulent exudates from all sites. The patient was discharged on postoperative day 22.

Thoracic necrotizing fasciitis due to snake ointment that progressed to a mediastinitis.

We report the case of a 42-year old diabetic male presenting with erythema of the neck and anterior right thoracic region secondary to the application of an ointment derived from rattlesnakes, progressing to a full-blown necrotizing fasciitis in a short period of time, with associated mediastinitis, thrombocytopaenia and sepsis. The patient died despite aggressive multidisciplinary medical and surgical treatment. We present this case due to the unusual aetiology and fulminating course.

[Pioneers of Mexican thoracic surgery]. / Pioneros de la cirugía torácica mexicana.

The development of thoracic surgery as a specialty is linked to the acquisition of knowledge and skills such as the resolution of the open pneumothorax with differential pressure and tracheal intubation, asepsis, antibiotic therapy and intensive care.Our pioneers in thoracic development were general surgeons who ventured into this field during the late nineteenth and early twentieth centuries, culminating in the transition to a full blown specialty during the second half of the 20th century.

Atypical intermediate-grade mediastinal carcinoid. Case presentation.

BACKGROUND: Approximately 25% of carcinoid tumors develop in the respiratory system. Neuroendocrine carcinoids represent ~5% of all mediastinal tumors and 1-5% of all intrathoracic neoplasms. They contain numerous neurosecretory granules that synthesize, store and release neurohumoral substances that can induce the carcinoid syndrome. CLINICAL CASE: A 21-year-old male presented with a rapidly progressive paraneoplastic syndrome unleashed by an acute urethritis. Two left mediastinal masses were identified and resected. Postoperative evolution has been uneventful during the first year. CONCLUSIONS: We emphasize the importance of early detection of primary and satellite lesions of these tumors including neurohumoral markers and PET/CT scans as in this case, as well as the participation of a multidisciplinary team.

Fibrinolytic therapy in left side-prosthetic valve acute thrombosis. In depth systematic review.

BACKGROUND: Limited data are available on the impact and safety of fibrinolytic therapy (FT) in left - side prosthetic valve acute thrombosis (PVAT). STUDY OBJECTIVE: To improve our knowledge about the FT role in left -side PVAT. DESIGN: Bibliographic search and analysis. METHODS: MEDLINE search from January 1970 to January 2007. Studies were classified according to the evidence level recommendations of the American College of Chest Physicians and included if they had objective diagnosis of left-side PAVT and FT efficacy assessment (hemodynamic, echocardiographic or fluoroscopic improvement). New York Heart Association class was used to establish functional state. Data on clinical characteristics, diagnosis strategy, anticoagulation status, fibrinolytic and heparin regimens, cardiovascular adverse events, outcome, and follow-up were also required. RESULTS: A systematic search produced a total of 900 references. Each abstract was analyzed according to the predetermined criteria. Thirty-two references with 904 patients constitute the subject of this analysis. Only one trial had evidence III and thirty-one evidence V. FT was more used in young female patients (64%) with prosthetic mitral valve thrombosis (77%), and clinical instability (82%). Transesophageal echocardiogram had a higher thrombus detection rate (100%). Although several fibrinolytic regimens were used in a first or second course, streptokinase was the most frequent agent (61%). Clinical improvement was observed in 86% of the patients, objective success in 78%, and failure in 14%. Rescue fibrinolysis was done in 17%. COMPLICATIONS: peripheral and cerebral embolism rate was 5% and 4%, respectively. Major bleeding 4% and intracranial hemorrhage 1%. CONCLUSIONS: The available evidence demonstrates that in PVAT fibrinolytic therapy improves the outcome in younger, more ill patients, especially females, independently of the fibrinolytic regimen used with a low complications rate.

Fibrinolytic therapy in left side-prosthetic valve acute thrombosis. In depth systematic review / Terapia fibrinolítica en el corazón izquierdo

BACKGROUND: Limited data are available on the impact and safety of fibrinolytic therapy (FT) in left - side prosthetic valve acute thrombosis (PVAT). Study objective: To improve our knowledge about the FT role in left -side PVAT. DESIGN: Bibliographic search and analysis. METHODS: MEDLINE search from January 1970 to January 2007. Studies were classified according to the evidence level recommendations of the American College of Chest Physicians and included if they had objective diagnosis of left-side PAVT and FT efficacy assessment (hemodynamic, echocardiographic or fluoroscopic improvement). New York Heart Association class was used to establish functional state. Data on clinical characteristics, diagnosis strategy, anticoagulation status, fibrinolytic and heparin regimens, cardiovascular adverse events, outcome, and follow-up were also required. RESULTS: A systematic search produced a total of 900 references. Each abstract was analyzed according to the predetermined criteria. Thirty-two references with 904 patients constitute the subject of this analysis. Only one trial had evidence III and thirty-one evidence V. FT was more used in young female patients (64%) with prosthetic mitral valve thrombosis (77%), and clinical instability (82%). Transesophageal echocardiogram had a higher thrombus detection rate (100%). Although several fibrinolytic regimens were used in a first or second course, streptokinase was the most frequent agent (61%). Clinical improvement was observed in 86% of the patients, objective success in 78%, and failure in 14%. Rescue fibrinolysis was done in 17%. Complications: peripheral and cerebral embolism rate was 5% and 4%, respectively. Major bleeding 4% and intracranial hemorrhage 1%. CONCLUSIONS: The available evidence demonstrates that in PVAT fibrinolytic therapy improves the outcome in younger, more ill patients, especially females, independently of the fibrinolytic regimen used with a low complications rate.

Tumor del mediastino anterior en hombre joven / Anterior mediastinal tumor in a young man

Se presenta el caso de un hombre joven con tumor sólido del mediastino anterior y superior, con elevación de algunos marcadores tumorales. El diagnóstico anatomopatológico fue seguido de quimioterapia.

A young man presented with a solid mass in the anterosuperior mediastinum and superior vena cava syndrome. Some tumor markers were elevated. Diagnosis was followed by chemotherapy.

Manejo quirúrgico del cáncer de pulmón. Hechos y algunas reflexiones / Surgical approaches to lung cancer. Facts and some reflections

El carcinoma broncogénico de células no pequeñas (CBCNP) en etapas I y II es tributario de resección completa, pero cada vez existe más evidencia de que la terapia de inducción preoperatoria y la adyuvancia posoperatoría pueden prolongar la sobrevida de enfermos en etapas IB y II. Algunos enfermos en la etapa IIIA debe recibir inducción y revalorar el mediastino por fusión TC/PET o remediastinoscopía antes de planear resección. Las etapas IIIB y IV no son operables, excepto casos muy seleccionados. Se hacen reflexiones a propósito del acceso de los enfermos de países en desarrollo a los nuevos avances médicos, farmacológicos y tecnológicos, del control del tabaquismo y de algunos aspectos éticos relacionados con el tratamiento médico y la cirugía del CBCNP.

Stage I and II non-small cell lung cancer (NSCLC) should be resected, but there is mounting evidence for the use of preoperative induction and postoperative adjuvant therapy in stages IB and II, as being able to prolong life. Some patients in stage IIIA should undergo induction therapy, and then have re-staging of the mediastinum by CT/PET or redo mediastinoscopy before considering resection. Stages IIIB and IV are non-surgical, except very selected cases. Reflections are made regarding the control of cigarette smoking, the difficult access of patients from developing countries to the recent costly medical, pharmacological and technical advances; reflections are also made related to some ethical issues regarding medical and surgical treatment of NSCLC.

Diagnóstico tardío de evisceración diafragmática secundaria a trauma torácico cerrado veintinueve años antes / Delayed diagnosis of rupture of the diaphragm 29 years after trauma

Mujer de 64 años, del medio rural, referida por imagen radiográfica anormal del tórax. Veintinueve años antes se había caído de un caballo, produciéndose una severa contusión torácica. Estudios con contraste del aparato digestivo mostraron visceras abdominales dentro del hemitórax izquierdo. La enferma rehusó corrección quirúrgica del defecto por estar, asintomática y sólo sentir "burbujas en el pulmón".

A 64 year old woman was referred by her rural doctor due toan abnormal chest X ray. Twenty nine years before she had fallen from a horse suffering a severe thoracic contusion. Contrast studies of the upper and lower gastrointestinal tract showed abdominal viscerae inside the left thoracic cavity. The patient refused surgical correction because she considered herself to be asymptomatic and her only complaint was "feeling bubbles in the lung".