EMERGENCY SURGICAL TRACHEAL DECOMPRESSION IN A HUGE RETROSTERNAL GOITER.

INTRODUCTION: Over the past decades, several definitions and classifications of cervico-mediastinal goiters have been proposed. We analyzed and discussed the clinical presentation, the diagnostic procedures and the surgical technique in relation to post-operative complications and long-term results in a case of a sixty-six years old obese, hypertensive female admitted in the Thoracic Surgery Department with respiratory distress (inspiratory dyspnea, stridor) progressively aggravating during the latest month. METHODS: Cervico-thoracic CT scan revealed the existence of a cervico-mediastinal huge goiter which developed mostly intrathoracic (2/ 3 of the goiter). It determined a tracheal compression, reducing its caliber by two thirds, and its displacement to the right side. The proposed surgical procedure was total thyroidectomy and it involved a bipolar approach (transcervical and transsternal) through a partial upper cervico-sternotomy. RESULTS: The complete removal of the goiter and the decompression of the trachea have been achieved. Postoperative results were very satisfactory, with the absence of the respiratory distress. The histological examination revealed a multinodular goiter with epithelium hyperplasia. CONCLUSION: The presence of a complicated cervico-mediastinal goiter with severe respiratory distress required a surgical excision as the main and immediate treatment option. The surgical procedure represented a milestone for both the anesthesiologist (difficult intubation, with a thin tracheal tube in the absence of the jet ventilation technology) and for the surgeon. The goiter's excision from the visceral mediastinum was very difficult because of its huge dimensions and close relations with trachea and great vessels (anterior) and esophagus, erector spinal muscles and the spine (posterior).

Giant thoraco-abdominal tumor -- a surgical challenge. Case report.

BACKGROUND: During the last three decades, several improvements in surgical and anesthetic techniques have allowed a better management of primary and secondary tumors of the chest wall. OBJECTIVES: Chest wall tumors, regardless of their location,anterior, posterior or lateral, have always been a challenge for the thoracic surgeon through technical and tactical problems they entail. The most common techniques to reconstruct a full thickness defect are by the use of alloplastic material and filling the soft tissue defect with myocutaneous flap. METHOD: We present the unusual case of a 45 years old patient with a giant right thoraco-abdominal tumor, developing for the last 22 years. The tumor occupied the lower half of the right hemithorax and the right hemi abdomen, down to the right iliac crest. The tumor also developed inside the thoracic cavity, with the invasion of the last 3 ribs, of the diaphragm(partial) and with intra-abdominal invasion of a liver section and the right kidney. RESULTS: The surgery team had special problems related to:providing training and logistics, in-block tumor resection in oncological limits, followed by complex thoraco-abdominal reconstruction. The results were very good, with a favorable postoperative evolution, without any complications, the patient being discharged with the recommendation to come for follow-up on his condition. CONCLUSIONS: A complex surgical intervention proved to be the only solution for saving the patient, for which the life due to the tumor's size became almost unbearable.

Cervico-mediastinal thyroid masses - our experience.

INTRODUCTION: Over the last decades, several definitions and classifications of cervico-mediastinal goiters and thyroid masses have been proposed. We analyze and discuss the clinical presentation, the diagnostic procedures and the surgical technique in relation to post-operative complications and results in cervico-mediastinal thyroid masses admitted in our Clinic of Thoracic Surgery over a period of 22 years (1991-2012). METHODS: We reviewed 130 patients who underwent surgery for retrosternal thyroid masses, 77 (59.23%) women and 53(40.77%) men. Mean age was of 53 years. Shortness of breath was observed in 71 (54.61%) patients as the most frequent preoperative symptom. Cervico-thoracic CT scan reveales the existence of a cervico-mediastinal mass and can appreciate the degree of intrathoracic progression, tracheal compression and dislocation, as well as the relations with other anatomical structures of the visceral mediastinum. All 130 patients were prepared for a thoracic approach, majority of the cases were operated by Prof. T. Horvat. The surgical procedure was performed by cervical approach only in most of the cases (106 cases) (Kocher type cervicotomy in 63 cases and Horvat type "en-Y" cervicotomy in 43 cases). We used a bipolar approach for large cervico-thoracic masses: cervicotomy and partial upper sternotomy in 20 cases, cervicotomy and full sternotomy in 3 cases, cervicotomy and right axillary thoracotomy in one case. RESULTS: The removal of the thyroid mass and decompression of the trachea have been achieved in all cases. Post operative results were very satisfactory, with absence of respiratory distress and with normal function of the vocal cords. No post operative mortality was encountered. CONCLUSION: The presence of a cervico-mediastinal thyroid mass with or without respiratory distress requires a surgical excision as the only treatment option. The surgical procedure represented a milestone for both anesthesiologist (difficult intubation in some cases of large goiters) and thoracic surgeon.Thyroid masses extending to the mediastinum can be excised successfully by cervical incision. Bipolar approach has an excellent outcome, achieving a safe resection, especially in large thyroid masses extending to the mediastinum with close relations to mediastinal structures.

[Minimally invasive surgery in the treatment of malignant pleuro-pericardial effusions]. / Chirurgia miniinvaziva în tratamentul pleuro-pericarditelor maligne.

INTRODUCTION: Malignant pleuro-pericardial effusions (MPPEs) are a common problem in the treatment of patients with cancer and may occur with any malignancy. METHODS: Between 01.01.1998 -31.12.2008 we conducted a retrospective study. During this period of time 46 patients were diagnosed and treated for malignant pleuro-pericardial effusions in Clinic of Thoracic Surgery under Prof. Teodor Horvat coordination (from SUUMC). RESULTS: In this study a total of 42 MPPEs have been approached through minimally invasive procedures (36 patients underwent thoracoscopic procedures and 6 patients were subjected to VATS). In our study, the pulmonary cancers were the most frequent primary cancers who caused MPPEs (22 cases). The thoracoscopic pleuro-pericardial window was the most frequent and efficient procedure used for pericardial drainage (34 cases). Effective control of the recurent malignant pleural and pericardial effusions was made most frequent through postoperative pleural bleomycin instillation (22 cases) and through thoracoscopic insufflation of talc in 14 cases. CONCLUSIONS: The minimally invasive thoracic surgery is a safe and efficient method for diagnosis and treatment of pleuro-pericardial effusions.

[A giant thoracoabdominal tumor--hereditary multiple exostoses]. / Tumora giganta toracoabdominala. Maladia exostozanta ereditara.

Hereditary multiple exostoses (HME), also known as osteochondromatosis, is an inherited, autosomal dominant disorder in which multiple osteochondromas develop throughout the skeleton. We present the case of a 17 years old boy diagnosticated with HME with multiple prior orthopedic interventions for upper and lower limbs deformant osteochondromas. He was admitted in our service for a giant osteochondroma localized at the left thoraco-abdominal border arising from C11, C12 ribs, involving the thoracic postero-bazal wall, the abdominal posterior wall and practically the entire left retroperitoneal space. We performed the total resection of this giant tumor (2.6 kg) with postero-inferior thoracic parietectomy (10 to 12 ribs) and abdominal postero-lateral parietectomy followed by the thoraco-abdominal parietal reconstruction with a dual-mesh soft tissue patch, after the high reinsertion of the left diaphragm. The postoperative results were very good from both points of view: esthetical and functional, with preservation of the diaphragm activity and the anatomical reposition of the abdominal viscera. The paper refers to the etiopathogenesis, clinical symptoms, diagnostic, and therapeutic considerations of HME.

[Pleurotomy--an operation by the general surgeon]. / Pleurotomia -- operatie la îndemâna chirurgului generalist.

The authors present the newest data of a minimal thoracic technique: the pleurotomy. In our times this technique requires the modem chest tubes, the complete pleurotomy sets for different emergent situations. The authors presents the indications, the possible complications, their own technique of pleurotomy and the actual management of pleural drainage.

[Recto-vesical and recto-vesico-vaginal fistulae caused by radiotherapy for carcinoma of the uterine cervix. Surgical treatment]. / Fistulele recto-vezicale si recto-vezico-vaginale postradice dupa neoplasm al colului uterin. Tratament chirurgical.

The authors present a study based on 4 cases of fistulous communication between the terminal digestive tube and the genitourinary tract, which appeared after surgery and radiation therapy for carcinoma of the uterine cervix. The diagnosis criteria (symptoms, clinical and imagistic findings), the objectives of the surgical treatment (external digestive derivation, treatment of the fistula and reconstruction of the digestive tube), the steps of the operation and the early and late postoperative evolution are pointed out. The conclusions are shown at the end.

[Gastrojejunocolic fistula after transmesocolic gastrojejunostomy for stenotic duodenal ulcer]. / Fistula gastro-jejuno-colica dupa gastro-jejunostomie transmezocolica pentru ulcer bulbar stenozant.

The authors are presenting the case of a 53 year-old patient, suffering from type II diabetes mellitus and ankylosing spondylitis, admitted in our clinic in July 1997 for gastrojejunocolic fistula, 5 years after a transmesocolic gastrojejunostomy for obstructive chronic duodenal ulcer. The severe metabolic disorders and the radiologic aspects which led to the diagnosis, as well as the morphopathologic lesions found and the ways to approach the fistula, the stenotic duodenal ulcer and the reconstruction of the digestive continuity in a single surgical procedure are further discussed. The conclusions are shown at the end.