VATS therapy of chylothorax caused by leiomyomatosis complicated with tuberous sclerosis complex.

Lymphangioleiomyomatosis with tuberous sclerosis complex is a rare disease. One of the most frequent complications of lymphangioleiomyomatosis is pleural effusion (chylothorax) wich can be treated with the use of VATS. Authors report a case of pulmonary lymphangioleiomyomatosis in a 56-year-old female patient with tuberous sclerosis complex with an 8-week history of recurrent chylothorax, dyspnea and debilitating weakness. By CT scan a flat tissue proliferation was seen in the site of the thoracic duct and it was supposed to be the reason for the pleural effusion. A VATS resection of this laesion and ligation of the thoracic duct was performed successfully. Chylothorax is often associated with pulmonary lymphangioleiomyomatosis. Lymphangioleiomyomatosis combined with tuberous sclerosis complex is extremely rare. In case of chylothorax VATS treatment is successful and may be the first choice.

[The treatment of spontaneous pneumothorax--focusing on the use of videothoracoscopy]. / A spontán pneumothorax kezelése különös tekintettel a videothoracoscopiára.

AIMS: Videothoracoscopy plays a leading role in the management of spontaneous pneumothorax. This study evaluates various treatment strategies based on early results. PATIENTS AND METHODS: In a five-year period 243 (184 male, 59 female, mean age: 37.1 years) patients were treated with spontaneous pneumothorax in 302 cases. In case of partial ptx observation was used in 24 (8%) and aspiration in 6 (2%) patients. Chest drain was inserted in 241 (67.6%) cases. Indications for surgery were recurrence of disease, previous contralateral pneumothorax and failure of drainage. Videothoracoscopy was indicated in 71 (23.5%), Jakoscopy in 5 (1.7%), thoracotomy in 13 (4.3%) cases. The operation was completed with partial pleurectomy in 25, talcum or mechanical pleurodesis in 32 and 3 cases, respectively. RESULTS: Conservative treatment was successful in 24 (80%) of the 30 conservatively treated cases, while chest drainage succeeded in 204 (84.7%) of the 241 cases. Conversion was needed in 8 (11.3%) cases of the 71 VATS. The remaining 63 patients recovered. Thoracotomy and Jakoscopy were successful in all cases. The postoperative complication rate was 6.3% after VATS, and 7.7% after thoracotomy. Reoperation was performed because bleeding in one case after VATS and thoracotomy. In one case empyema, and in another patient pneumonia developed after VATS. Postoperative bleeding occurred in one case after thoracotomy. The mean hospitalization was 8.5 days after drainage, 9.1 days after VATS and 11.3 days after thoracotomy. The postoperative mortality rate was 1.3% (4 patients). CONCLUSIONS: In case of spontaneous pneumothorax the first choice of therapy is chest tube drainage. VATS is indicated in case of recurrence, failure of drainage and previous contralateral pneumothorax.

[A complicated case of spontaneous oesophageal rupture managed by transgastric drainage]. / Spontán nyelocsoruptura komplikált esetének megoldása transgastricus drainage-zsal.

Spontaneous rupture of the oesophagus is an extremely serious condition with high morbidity and mortality. Primary surgical repair may be followed by numerous complications. A 29-year-old man had undergone primary surgical repair due to spontaneous rupture of the lower third of the oesophagus. After the operation he developed suture insufficiency, which could not have been stented, and transgastric drainage was performed therefore. After a slow healing of the fistula, we could avoid another operation and his oesophagus was preserved. Fortunately, a stricture did not develop either. Transgastric drainage of the oesophagus could be a good therapeutic choice in selective and complicated cases.

[Intrathoracic migration of Kirschner wires]. / Kirschner-drótok intrathoracalis vándorlása.

Orthopedic surgeons apply metallic pins to stabilize the clavicule and humerus on a daily basis. Migration of these pins into the thoracic cavity is rare. We present the case of an elderly female patient, whose right humeroscapular joint was fixed with Kirschner wires due to recurrent luxation. Six weeks later, a follow-up X-ray revealed that the pins have migrated into the right thoracic cavity, confirmed by a CT chest. Videothoracoscopic removal of the metallic pins was not possible because of dense adhesions. Right anterolateral thoracotomy was carried out, and after pneumolysis one pin was taken out from the 2nd lung segment. The other one, which was running along the cupola and entering the spinal cord, was also removed. There was no postoperative surgical complication. The authors review the literature of this rare complication and point out that pins migrating into the thoracic cavity should be removed to avoid life threatening complications.

[Anaesthesia of the myasthenic patients during thymectomy]. / Myastheniás betegek altatása thymectomia során.

Myasthenia is a rare autoimmune disease characterized by fluctuating muscle weakness and fatigability due to a reduction in available acetylcholine receptors at the neuromuscular junction. Data of 186 patients suffering from myasthenia were collected retrospectively. All patients underwent thymectomy over a 23 years period from 1981 to 2006 without surgical mortality. Postoperative ventilation was required for more than 24 hours in seven patients and one patient needed postoperative ventilatory support more than seven days. Thymectomy for myasthenia was performed using promethazine and atropine in general anaesthesia. Introduction could be facilitated with propofol, etomidate or thiopental and sevoflurane, avoiding use of any muscle relaxants. Non-depolarizing muscle relaxants were not used during the procedures. Adequate surgical conditions were provided by short-acting inhaled anaesthetics (sevoflurane) and small doses of opiates. 95% of the narcotized patients were immediately extubated after the procedure in the operating room. Length of stay in intensive care unit could have been reduced without any postoperative ventilatory support. Nonsteroid analgesics and nalbuphine were used for pain relief. Anaesthesia of thymectomy is based on volatile gases. Airway complications can be prevented with use of small amounts of anticholinergic drugs, perhaps steroids.

[Current issues in the diagnosis and treatment of penetrating chest trauma]. / Athatoló mellkassérülések diagnózisának és kezelésének idoszeru kérdései.

INTRODUCTION: Successful treatment of penetrating chest trauma largely depends on the accurate and rapid diagnostic work-up, as well as the adequate surgical management. The authors discuss current issues in the diagnosis and the treatment of penetrating chest injuries based on the analysis of 109 cases. PATIENTS AND METHODS: 82 men and 27 women with penetrating chest trauma were studied. The average age of the patients was 37.8 years. The injury was caused by stabbing in 104 cases (95.4%), gunshot in 4 patients (3.7%) and explosion in one case (0.9%). 41 patients had cardiac and pericardial injuries. In those, 19 (46.3%) patients had a chest X-ray, echocardiography was done in nine cases (22%), while CT scan and diagnostic VATS were performed in two patients, respectively. All patients underwent surgery except one, who was treated conservatively.In all of the 68 patients, who had no cardiac injuries, a chest X-ray was performed. Echocardiography was done in six (8.8%) cases, diagnostic VATS in four (5.9%) patients, and abdominal ultrasound scan in 3 (4.4%) cases. Chest tube was inserted in 13 patients (19.1%), an open surgery was performed in 51 cases, while in 4 cases VATS was carried out. RESULTS: In the group of patients with cardiac and pericardial injuries, the sensitivity of the chest X-ray, echocardiography and VATS were 57.9%, 88.9% and 100%, respectively. Further, specificity of the above were 26.3%, 88.9% and 100%, respectively. However, in patients with non-cardiac injuries, the sensitivity of the chest X-ray was 100%, and both the specificity and sensitivity of VATS was 100%. Postoperative complication rate was 12.6% overall (15% in cases with cardiac injury and 10.9% in the non-cardiac subgroup). Mortality rate was 7.3% among the patients with cardiac injury, while there was no mortality detected in the non-cardiac subgroup. The average mortality rate was 2.8%. CONCLUSION: Patients with penetrating chest trauma should undergo a rapid and accurate diagnostic work-up followed by an adequate surgical management in order to keep their prognosis relatively good.

[The role of VATS in the treatment of blunt thoracic injuries]. / A VATS szerepe a tompa mellkasi serülések kezelésében.

AIMS: Video assisted thoracoscopy (VATS) is a more and more frequently used method in the diagnosis and treatment of blunt thoracic trauma. In some cases it has diagnostic and in others therapeutic effect. The authors analyze the role of VATS in the diagnosis and the treatment of 83 patients treated with haemothorax. PATIENTS AND METHODS: There were 83 patients treated (60 male, 23 female, mean age of 54.4 years) with haemothorax caused by blunt thoracic trauma. Chest tube drainage was used in 31 (37.3%) cases. Urgent thoracotomy was performed in only two (2.4%) cases. Elective, planned VATS was used in 11 (13.3) cases. All of these 3 were diagnostic and 8 were therapeutic procedures. In three cases rupture of the diaphragm was diagnosed with the use of VATS which were treated through thoracotomy. In the remaining 8 cases haematoma evacuation and in 3 cases intercostal artery bleeding were treated with VATS. RESULTS: No complications related to the procedure were observed. The thoracotomy in all 3 cases verified the diaphragmatic injuries. The 8 patients undergone therapeutic VATS recovered. The mean hospital stay after VATS was 7.8 days and 11.3 days after thoracotomy in the patients with diaphragmatic injury. CONCLUSIONS: The VATS has a significant role in the diagnosis of blunt thoracic, especially of diaphragmatic, injuries. In other cases the VATS has good therapeutic effect.

[Surgical management of sternoclavicular joint infections]. / Sternoclavicularis ízület fertözésének sebészi kezelése.

AIMS: The pyogenic infection of the sternoclavicular joint is a rare disease. The treatment can be conservative (antibiotics) or surgical (exposure and drainage of the joint or its resection). The authors analyze the causative and predisposing factors, the symptoms, the diagnosis, the questions of the therapy and its efficiency. PATIENTS AND METHODS: In the 6 cases (5 male, 1 female, average age: 56.8 years) the cause of the disease were trauma or metastatic septic focus in 2-2 cases and intraarticular injection or preceding radiotherapy in 1-1 case. Predisposing diseases (diabetes mellitus, gout, chronic alcoholism, liver cirrhosis) could be proved in two cases. The most frequent symptoms were the swelling and erythema of the joint, fever, pain and limitation of motion. In all cases the CT scan proved the destruction of the joint. In one case after unsuccessful conservative therapy and in 1-1 case after debridement and drainage because of concomitant multiple septic focuses and mediastinitis resection of the sternoclavicular joint was applied in a later second step. In the other three patients primary resection of the joint was performed. RESULTS: Both the conservative and drainage managements were insufficient. On the other hand the radical joint resection caused complete recovery in all cases. No intra and postoperative complications were observed. On an average 28.2 months after the radical operation the functional results were excellent. CONCLUSIONS: Relying upon the results, radical resection is supposed to be the most effective method. Conservative treatment or drainage are recommended only for cases associated with severe complications. Resection is worthy performing after the recovery of the concomitant illnesses.

[Balloon dilatation of cervical anastomosis stricture after subtotal resection of the esophagus]. / Szubtotális nyelócsó-resectio után kialakult nyaki anastomosisszukület endoszkópos tágítása és annak eredményei.

AIMS: The stricture of the anastomosis is one of the most common complications of the subtotal esophageal resections. The authors present indications, technics and results of the endoscopic dilatation. PATIENTS AND METHODS: In a 10 year period 26 patients (22 male, 4 female, mean age of 53.7 years) with stricture of anastomosis between the esophagus and the neo-esophagus after subtotal esophageal resection were dilated endoscopically 82 times. The indication of the resection was tumour in 23 (88.5%) cases, congenital atresia in 2 (7.7%) cases and corrosive disease in one (3.8%) case. In 7 (31.8%) cases the stricture developed after anastomosis leakage. The mean time between the operation and the dilatation was 7.8 months. The cause of the stricture was cancer recurrency in 4 (15.4%) cases. RESULTS: There were no complications related to the dilatation. The mean number of the dilatation was 3.2 (1-9). There was no significant difference between the number of dilatation in patients with or without previously anastomotic leakage. The success rate of the dilatation for benign strictures was 95.5%. In only one patient (4.5%) was needed operative intervention. In the 4 patients with tumour recurrency a stent was also implanted in the stenosis. CONCLUSIONS: The endoscopic dilatation for the treatment of the cervical anastomosis stricture after subtotal esophageal resection is a successful method with a low rate of complications. In cases of tumour recurrency a stent implantation is suggested.

[Endoscopic stapled esophago-diverticulostomy as a new alternative to open surgery in the treatment of Zenker's diverticulum: which operation?]. / Endoszkópos oesophago-diverticulosto- mia, mint újabb lehetoség a Zenker diverticulum nyitott mutéti kezelése mellett: melyik mutétet válasszuk?

AIMS: The authors analyse the indications, contraindications, early and late results of two types of operations (resection of the diverticulum with crycopharyngeal myotomy and endoscopic stapled esophago-diverticulostomy) for the treatment of Zenker's diverticulum. PATIENTS AND METHODS: In a five year period 10 patients (5 male, 5 female, mean age 56.9 years) were operated for Zenker's diverticulum. Six open and 4 endoscopic operations were planned, although in one case the placement of the endoscope was unsuccessful. Open surgery was planned if the diverticulum was in lateral position, if it was too small or large and if endoscopic surgery was technically impossible. RESULTS: The operative time was shorter in the endoscopic group (32.3 vs. 80.7 minutes). In the open surgery group (7 patients) one saliva fistula developed caused by suture leak. The length of hospital stay was 8.1 days in the resection group and 4.7 in the endoscopic group. No recurrence developed. CONCLUSIONS: The advantages of the endoscopic oesophago-diverticulostomy are: shorter operating time and hospital stay, less complication rate and it is minimally invasive. The authors suggest endoscopic oesophago-diverticulostomy as the choice of operation in case of Zenker's diverticulum. Open surgery is indicated only if the diverticulum is in lateral position or if it is bigger than 8 cms. The technical contraindications for endoscopic surgery are: short, rigid neck and limited mouth opening.

[Changes in surgical therapy of pulmonary hydatid cysts]. / Változások a tüdo echinococcus ciszta sebészi kezelésében.

The lung is the second most common site of hydatid cysts after the liver. The authors analyse retrospectively the results of patients treated with pulmonary hydatid cysts in the past 18 years, considering video-thoracoscopy. Twenty eight patients were treated during this period in 31 cases. Hydatid disease affected only the lung in case of 22 patients, while in 6 cases it was present in the liver and lung simultaneously. Pulmonary hydatid disease affected one side in 24 and both sides in 4 cases. For surgical treatment pericystectomy in one, atypical segment resection in 18, anatomical segmentectomy in three, lobectomy in 7 and video-thoracoscopy in 3 cases were performed without surgical complications. The mean hospital stay was 10.5 days in case of thoracotomies and 8.5 days in case of video-thoracoscopy. There was one recurrence in conventional surgery and reoperation was necessary. After video-thoracoscopy no recurrence was detected. Mean follow-up was 120 months, after video-thoracoscopy it was 20 months. Three patients have uncertain chest pain after thoracotomy, but none has any complaints after video-thoracoscopy. Fifteen patients took mebendazole permanently after the final histological result. According to the authors' practice the indication of lung resections for pulmonary hydatid cysts is limited, in selective cases video-thoracoscopic cystectomy can be a successful treatment of choice.