A prospective evaluation of video-assisted thoracic surgery for persistent air leak due to trauma.

BACKGROUND: The time required for air leak resolution after chest trauma is not well described. Based on an institutional review of posttraumatic air leaks our hypothesis was that video-assisted thoracic surgery (VATS) for persistent posttraumatic air leak would decrease chest tube days and length of stay compared with nonoperative management. METHODS: Patients were offered VATS versus nonoperative management when air leaks persisted longer than 3 days and the patients were otherwise ready for discharge. Chest tube days and length of stay were recorded. RESULTS: Of 223 trauma patients requiring chest tubes, 50 had persistent air leaks, 39 of whom were otherwise ready for discharge. Twenty-five chose VATS and 14 nonoperative (NOP) treatment. The mean chest tube days was 8.1 for VATS versus 11.8 for NOP (P = 0.001). Mean length of stay was 9.7 days for VATS and 16.5 days for NOP (P = 0.002). CONCLUSIONS: In patients otherwise ready for discharge VATS reduces chest tube days and length of stay when used to treat persistent posttraumatic air leak.

Baker's cysts mimicking the symptoms of deep vein thrombosis: diagnosis with venous duplex scanning.

PURPOSE: The purpose of this study was to determine the incidence and characteristics of Baker's cysts discovered during venous duplex examinations to rule out deep vein thrombosis (DVT). METHODS: We reviewed the vascular laboratory charts of patients found to have Baker's cysts during venous duplex studies to rule out DVT from October 1988 through December 1995. RESULTS: Ninety-five (3.1%) of 3072 patients who underwent venous duplex studies were found to have 111 Baker's cysts. Seven of the 95 had coexistent DVT. Ten patients had ruptured cysts, whereas six patients had cysts that compressed the popliteal vein. CONCLUSION: The presentation of DVT and that of a Baker's cyst are similar enough to be difficult to distinguish by clinical examination. Careful examination of the popliteal fossa should be performed during venous duplex examinations regardless of the indication for the study.

Role of venous duplex scanning in patients with suspected pulmonary embolism.

PURPOSE: We examined the use of venous duplex scanning (VDS) in the diagnosis of pulmonary embolism (PE) at our institution. METHODS: Patients undergoing lower extremity VDS from October 1988 through June 1995 were cross-referenced with those who underwent ventilation perfusion (V/Q) scans and pulmonary angiography (PA) for PE. RESULTS: A total of 664 of 3534 VDS were for "rule out PE." Deep venous thrombosis was found in 13%. A total of 256 VDS were in conjunction with V/Q scans in 249 patients, with only 8% undergoing PA. Deep venous thrombosis was present in 18% for those with both V/Q and VDS compared with 10% (p < 0.01) for those with VDS as the sole study. The order in which V/Q, VDS, and PA were obtained and the relationship of positive studies was examined. CONCLUSION: We found no pattern to the sequence of tests ordered. V/Q scan rather than VDS should be the first study in the evaluation of PE. PE was diagnosed or excluded in nearly one third of patients based on V/Q as the initial study. A total of 29% of VDS could have been avoided. Treatment could be determined on the basis of VDS as the initial study in only 13%. We found only 14% incidence of positive PA in patients with nondiagnostic V/Q scans. We advocate judicious use of diagnostic tests in a stepwise fashion to appropriately treat patients with suspected PE.

Prolongation of canine islet allograft survival by 15-deoxyspergualin.

Previously we have shown that nonsteroidal, multimodal immunosuppression consisting of cyclosporine (CsA), azathioprine (AZA), and RBC-absorbed goat anti-dog lymphoblast globulin (ALG), at doses considered tolerable in humans, results in limited canine islet allograft survival. Regimens including the diabetogenic agent prednisone are even less successful. In our search for an immunosuppressive regimen that could be applied to human islet transplantation, we tested the effect of 15-deoxyspergualin (DSG) in a canine model. Animals received either CsA, 20 mg/kg/day; AZA, 2.5 mg/kg/day; and ALG, 20 mg/kg/day x 14 days (Group I) or CsA, AZA, ALG at the same doses with the addition of low dose DSG, 0.5 mg/kg/day (Group II). Trough CsA levels by high pressure liquid chromatography ranged in both groups between 100 and 200 micrograms/liter. Rejection of the islets was diagnosed when serum glucose remained greater than 200 mg/dl for 3 consecutive days. There was no significant difference in the number of islets per kilogram of body weight of recipient transplanted in Group I and Group II (5754 +/- 2544 islets/kg versus 7953 +/- 3440 islets/kg, respectively). Animals receiving ALG, CsA, and AZA alone achieved a median islet allograft survival of 4 days, with a mean of 10.8 days. However, with the addition of low-dose DSG, median islet allograft survival was improved to 22 days, with a mean of 32.4 days (P = 0.012, Mann-Whitney test). We conclude that the addition of low-dose DSG to an ALG induction, cyclosporine-based immunosuppressive regimen enhances canine islet allograft survival and has potential for application in clinical islet allotransplantation.