Herniation of the lung after video-assisted thoracic surgery.

We report a case of lung herniation occurring following video-assisted thoracic surgery. Although lung hernias are rare, the widespread application of video-assisted thoracic surgery to patients at risk for lung hernia will likely result in more reports in the future. Consequently, pulmonologists and thoracic surgeons must be aware of this condition, risk factors for development, and potential methods of prevention in order to minimize the occurrence of this complication.

The use of adenosine for repair of penetrating cardiac injuries: a novel method.

The use of intravenous administration of adenosine to expedite cardiorrhaphy in penetrating cardiac trauma by inducing temporary asystole is described. It is quicker, more effective, and safer than the traditional methods.

The lingula is an appropriate site for lung biopsy.

BACKGROUND: Lung biopsy is commonly performed for diagnosis of diffuse pulmonary disease. The lingula offers technical advantages for biopsy, however the quality of tissue obtained by lingula biopsy has been questioned. We sought to determine whether lingula biopsy was a satisfactory site for biopsy in terms of diagnostic yield, therapeutic interventions, and survival results. METHODS: All diagnostic lung biopsies performed for diffuse lung disease at 3 university affiliated hospitals between July 1, 1992 and December 31, 1998 were retrospectively reviewed. Patients were divided into 2 groups, depending upon site of biopsy: patients with lingula biopsy only and those with biopsies from other sites. RESULTS: There were 75 patients; 20 underwent biopsy of the lingula alone, 48 had biopsy of other sites with or without biopsy of the lingula, and location of biopsy was unknown in 7 patients. Histologic diagnosis was achieved in all patients. Significant beneficial therapeutic changes were made in 14 lingula patients, and consisted of immunosuppression in 12 cases. Three patients died in the hospital or within 30 days. Fourteen patients survived 1 year. There was no significant difference between patients that had biopsy of the lingula alone and those that had biopsies from other sites in urgency, technique, histologic diagnosis, rate of therapeutic interventions, hospital mortality, or 1 year survival. CONCLUSIONS: Lung biopsy of the lingula compared to other anatomic sites has equivalent diagnostic yield, therapeutic significance, and survival. Given the technical ease of biopsy, when disease is present radiographically it is the preferred site for lung biopsy.

Heterotopic pancreas of the esophagus masquerading as Boerhaave's syndrome.

Heterotopic pancreas (HP) of the esophagus is rare. We report a patient with HP of the esophagus and review the presentation, treatment, and results of the nine previously reported cases. Two patients had cancer. This high incidence raises concerns that HP of the esophagus may be premalignant. Because surveillance endoscopy is not possible, all known or suspected esophageal HP should be treated surgically.

Rodeo related large animal injury: is protective head-gear warranted?

To compare rodeo associated large animal injuries to large animal associated trauma from other aetiologies in order to determine whether mandatory protective head-gear during rodeo is warranted. Retrospective analysis related to injury involving large animal admissions between 1 January 1990 and 31 December 1995. The setting is at the University of New Mexico Health Science Center, a level 1 trauma centre. All patients admitted with Injury Severity Scores of 1 or higher following large animal associated injuries. There were 140 admissions for which mechanism of injury was known. Thirty-nine occurred during rodeo competition and 101 occurred during other activities. Bovine associated activities were the aetiology in 34 (87%) of rodeo related injuries while equine related activities were the aetiology in 97 (96%) of non-rodeo related injuries (P<0.001). Rodeo related injuries involved the head and neck in five patients (13%) compared to 42 patients (42%) in non-rodeo activities (P=0.001). Mean Regional Injury Severity Score head and neck was 0.4 for injured rodeo riders and 1.5 for injured non-rodeo riders (P<0.001). Mean admission Glascow Coma Scale was 14.9 for rodeo-injured patients and 13.3 for non-rodeo-injured patients (P<0.001). Total ISS was significantly lower for rodeo injured patients (9.1 vs. 11.7, P=0.03). No rodeo injured patient died as a result of head injury. Mechanism of injury, ISS head, GCS, total ISS, and outcome differ between rodeo and non-rodeo injuries. While routine helmet use during non-rodeo events appears justified, mandatory use of helmets in rodeo events is unwarranted. Orthotics to protect the chest and abdomen are more likely to reduce morbidity and mortality for rodeo participants.

Lung biopsy: is it necessary?

OBJECTIVE: Lung biopsy is associated with substantial mortality rates. We reviewed our experience with this operation, primarily in patients with immunocompetence, to determine whether the results justify the continued performance of this procedure. METHODS: We conducted a retrospective review of all diagnostic lung biopsies performed at 3 university-affiliated hospitals between July 1, 1992, and December 31, 1998. RESULTS: There were 75 patients: 25 patients were treated electively, 17 were treated on an urgent basis, 27 patients on an emergency basis, and the urgency was unclear in 6 patients. Significant beneficial therapeutic changes were made in 15 of 25 elective procedures (60%), in 16 of 17 urgent procedures (94%), and in 11 of 27 emergency procedures (41%; P =.001). Significant beneficial therapeutic changes consisted of immunosuppression in 13 of 15 (87%) patients treated on an elective basis, in 9 of 16 (56%) treated on an urgent basis, and in 9 of 11 (82%) treated on an emergency basis in whom therapy was altered (P =.14). Operative death was 0 of 25 for elective operations (0%), 3 of 17 for urgent operations (18%), and 14 of 26 for emergency operations (54%). Multivariable analysis of operative death showed urgency to be the only significant predictor of death (P =.002). CONCLUSIONS: In patients with immunocompetence, elective and urgent lung biopsies have acceptable operative mortality rates and frequently result in important beneficial therapeutic changes. Consequently biopsies are appropriate in these patients. Emergency biopsies are associated with high operative mortality rates and rarely result in a therapeutic change other than immunosuppression. These patients should not undergo lung biopsy if they are in stable condition and should be treated empirically with immunosuppression without operation if their condition is deteriorating.

Selective protection of gray and white matter during spinal cord ischemic injury.

BACKGROUND: Ischemic injury in the gray matter is associated with excitatory amino acid neurotransmitters (EAA) release, and in the white matter is associated with intracellular sodium accumulation. We investigated the protective effect during spinal ischemia of the EAA antagonist, 2-carboxypiperazinyl-propylphosphonic acid (CPP), and the sodium channel blocker (2,6-dimethylphenylcarbamoylmethyl) triethylammonium bromide (QX). METHODS: Sprague-Dawley rats were randomized in four groups, received intrathecally 10 microL of saline, CPP, QX, or QX/CPP, and underwent balloon occlusion of the aorta. Proximal pressure was lowered by exsanguination. In the acute protocol, 28 rats were used to calculate the length of occlusion, resulting in paraplegia in 50% of animals (P50). In the chronic study, 60 rats underwent 11' occlusion. The chronic animals were scored daily for 28 days and submitted to cord histology. RESULTS: The P50 of QX (11'22") and QX/CPP (11'54") were longer than saline (10'39"), suggesting a beneficial effect. Neurologic scores of all treatment groups (p = 0.0001) and histologic scores of CPP (p = 0.003) and QX/CPP (p = 0.002) were better than saline. CONCLUSIONS: Protection of spinal cord during ischemia can be achieved with intrathecal administration of selective agents directed to the gray and white matter.

Catastrophic hemorrhage on sternal reentry: still a dreaded complication?

BACKGROUND: To define the incidence of catastrophic hemorrhage (CH) during reoperations, the experience of the University of New Mexico was reviewed and compared with the practice of surgeons contacted by questionnaire. METHODS: At the University of New Mexico, 610 reoperations were reviewed and 210 deemed high risk because of multiple reoperation, aneurysm, patent grafts, chamber's enlargement, conduit or previous mediastinitis. In the questionnaire, we asked about reentry technique, occurrence and outcome of CH, and precautions for high-risk patients. RESULTS: At the University of New Mexico there were 4 CH with 1 death, and in the questionnaire there were 2,046 CH with 392 deaths. Our rate per surgeon was lower than that of the questionnaire. Rate of CH according to the saw was 2.09 for reciprocating, 2.0 for sagittal, and 1.74 for stryker in the questionnaire. Our rate was lower (0.65) with a micro sagittal saw. High-risk category predicted CH during sternotomy (p = 0.01) but only conduit (p = 0.005) was significant by univariate analysis. CONCLUSIONS: The risk of CH could be as high as 1%. The sagittal micro oscillating saw is the safest reported to date. Presence of a conduit increases the risk by 2.5 fold.

Transhiatal esophagectomy in a patient with aberrant right subclavian artery.

During transhiatal esophagectomy, the esophagus is generally safely and easily dissected posteriorly. However, in 1% to 2% of patients, an aberrant right subclavian artery passes between the esophagus and spine. We demonstrate that transhiatal esophagectomy may be safely performed in these patients when recognition and careful dissection are performed. Thoracic surgeons must be aware of this anomaly in order to prevent laceration of the aberrant right subclavian artery with catastrophic hemorrhage.

Mediastinitis without antecedent surgery.

The study evaluates the results of aggressive surgical treatment for mediastinitis without antecedent surgery, after retrospectively reviewing all patients with mediastinitis, excluding patients with prior cardiac, esophageal or mediastinal operations, treated between June 1, 1992 and August 1, 1996. 8 patients were treated. 7 were male, mean age was 58 years. The etiology was Boerhaave's syndrome in 4, iatrogenic injury in 2 and descending necrotizing mediastinitis in 2 patients. The mean number of operations was 2.5. The initial operation was through thoracotomy in 5 patients and sternotomy in 2 patients. 4 patients underwent neck drainage, 1 as primary treatment and 3 combined with transthoracic drainage. 1 patient received laparotomy. Mean hospitalization was 52 days (excluding 1 death). Complications included mechanical ventilation greater than 48 hours in 7 patients, 2 or more operations in 5 patients, multisystem organ failure in 5 patients and other complications in 6 patients. Death occurred in one patients. Mediastinitis without antecedent surgery is associated with significant morbidity, however, with aggressive surgical drainage 87% of patients survived.

Individuals at high risk for lung cancer have airway epithelial cells with chromosome aberrations frequently found in lung tumor cells.

Identification of individuals at greatest risk of developing lung cancer could enhance the efficacy of intervention modalities, thereby greatly reducing mortality from this disease. One strategy for identifying these people is to establish molecular markers which reflect the severity of their cancerization field. Thus, investigations were initiated to determine of cells with chromosome aberrations frequently exhibited by lung tumor cells, i.e., trisomy 7, trisomy 20, and deletion of 9p23, are prevalent within the uninvolved airways of cancer patients. As a result, cells containing these aberrations were consistently found at significantly elevated levels by using fluorescence in situ hybridization (FISH). In contrast, cells collected from non-smokers who had never smoked were normal by this assay. The next objective was to determine of cells exhibiting these alterations are also present in upper airways of exposed, but cancer-free smokers and ex-uranium miners. The results showed that, although only a subset of these people will develop lung cancer in their lifetimes, they universally harbor increased numbers of abnormal cells within their airway epithelium. However, the number of sites with multiple verities of abnormal cells tended to be fewer compared with the cancer patients. Thus, quantifying cells with molecular alterations within the cancerization field of a smoker may delineate those with a lesser grade of damage, and these individuals may be at a lesser risk of developing disease. However, differences in the extent of genetic damage afforded by these assays may not clearly define individuals with pending disease, and additional molecular assays must be devised.

Sequestration of the lung arising from the circumflex coronary artery.

Sequestration is an unusual pulmonary malformation. Systemic blood supply is commonly from the thoracic aorta, but arteries may occasionally arise from other sites including the abdominal aorta or the intercostal vessels. We report a rare form of sequestration with origin from the circumflex coronary artery. Knowledge of uncommon vascular origins, particularly from coronary arteries, is important to avoid injury and possible ischemia, infarction, exsanguination, or death.

Fissureless lobectomy.

Traditional lobectomy techniques describe division of pulmonary parenchyma within the fissures for access to the pulmonary artery. This results in air leaks, which may prolong chest tube drainage and hospitalization times. We describe a technique for lobectomy in which all lung parenchyma is divided using a stapler.

Videothoracoscopic treatment of hepatic hydrothorax.

Hepatic hydrothorax occurs frequently in ascites arising from communications in the diaphragm between peritoneal and pleural cavities. Numerous treatments have been described but are of limited utility due to invasiveness and poor success rate. We describe a case of hepatic hydrothorax in which the pore in the diaphragm was documented photographically and in which successful resolution was achieved with videothoracoscopic suture ligation and talc pleurodesis.

Head, face, and neck trauma from large animal injury in New Mexico.

BACKGROUND: Head, face, and neck injuries (HFNI) occur during animal-related trauma. We compared patients with HFNI and without HFNI after animal-related injuries to determine the significance of these injuries. METHODS: Retrospective review of admissions for animal injuries between January 1, 1990, and December 31, 1995, by age, gender, mechanism, animal, Glasgow Coma Scale (GCS) score, Injury Severity Score (ISS), Abbreviated Injury Severity score for head and neck (AIS Head/Neck), AIS score for face (AIS Face), intensive care unit stay, hospitalization length, morbidity, and mortality. RESULTS: There were 153 admissions: 61 HFNI and 92 no HFNI. Significant differences occurred in gender, animal, activity, GCS, and ISS. HFNI had higher AIS Head/Neck, AIS Face, and mortality. HFNI were from horses in 87% and occurred during recreation in 89%; 39% of patients with HFNI were 18 years or younger. CONCLUSION: HFNI occur in females and young people and produce lower GCS score, higher ISS, higher AIS Head/Neck, higher AIS Face, and higher mortality. Most occur during recreational horseback riding. Protective headgear should be mandated.

Detection of trisomy 7 in nonmalignant bronchial epithelium from lung cancer patients and individuals at risk for lung cancer.

Early identification and subsequent intervention are needed to decrease the high mortality rate associated with lung cancer. The examination of bronchial epithelium for genetic changes could be a valuable approach to identify individuals at greatest risk. The purpose of this investigation was to assay cells recovered from nonmalignant bronchial epithelium by fluorescence in situ hybridization for trisomy of chromosome 7, an alteration common in non-small cell lung cancer. Bronchial epithelium was collected during bronchoscopy from 16 cigarette smokers undergoing clinical evaluation for possible lung cancer and from seven individuals with a prior history of underground uranium mining. Normal bronchial epithelium was obtained from individuals without a prior history of smoking (never smokers). Bronchial cells were collected from a segmental bronchus in up to four different lung lobes for cytology and tissue culture. Twelve of 16 smokers were diagnosed with lung cancer. Cytological changes found in bronchial epithelium included squamous metaplasia, hyperplasia, and atypical glandular cells. These changes were present in 33, 12, and 47% of sites from lung cancer patients, smokers, and former uranium miners, respectively. Less than 10% of cells recovered from the diagnostic brush had cytological changes, and in several cases, these changes were present within different lobes from the same patient. Background frequencies for trisomy 7 were 1.4 +/- 0.3% in bronchial epithelial cells from never smokers. Eighteen of 42 bronchial sites from lung cancer patients showed significantly elevated frequencies of trisomy 7 compared to never smoker controls. Six of the sites positive for trisomy 7 also contained cytological abnormalities. Trisomy 7 was found in six of seven patients diagnosed with squamous cell carcinoma, one of one patient with adenosquamous cell carcinoma, but in only one of four patients with adenocarcinoma. A significant increase in trisomy 7 frequency was detected in cytologically normal bronchial epithelium collected from four sites in one cancer-free smoker, whereas epithelium from the other smokers did not contain this chromosome abnormality. Finally, trisomy 7 was observed in almost half of the former uranium miners; three of seven sites positive for trisomy 7 also exhibited hyperplasia. Two of the former uranium miners who were positive for trisomy 7 developed squamous cell carcinoma 2 years after collection of bronchial cells. To determine whether the increased frequency of trisomy 7 reflects generalized aneuploidy or specific chromosomal duplication, a subgroup of samples was evaluated for trisomy of chromosome 2; the frequency was not elevated in any of the cases as compared with controls. The studies described in this report are the first to detect and quantify the presence of trisomy 7 in subjects at risk for lung cancer. These results also demonstrate the ability to detect genetic changes in cytologically normal cells, suggesting that molecular analyses may enhance the power for detecting premalignant changes in bronchial epithelium in high-risk individuals.