OBJECTIVES: Thoracoscopy is an effective treatment method for pleural empyema; however, it is still not well defined as to which patient subgroups could benefit from it the most. The aim of the study was to identify preoperative factors that could facilitate selecting appropriate surgical intervention and to evaluate early postoperative period. METHODS:Seventy-one patients were prospectively included in the study, which was conducted from January 2011 to June 2014. Thoracoscopic surgery for Stage II/III pleural empyema was performed in all patients. Thoracoscopy failed in 18 (25.4%) patients, requiring conversion to thoracotomy. The preoperative factors that could possibly predict conversion were analysed.RESULTS: Obliterated pleural space (12 patients) and failure to achieve lung re-expansion (6 patients) were the main reasons for conversion. Multivariable logistic regression analysis demonstrated that each day of illness [odds ratio 1.1 (95% confidence interval 1.0-1.2], P = 0.004] and frank pus [odds ratio 4.4 (95% confidence interval 1.2-15.3), P = 0.021] were independent predictors of conversion. Using receiver-operating characteristic analysis, it was determined that the duration of illness had a high predictive value for conversion [area under the curve 0.8 (95% confidence interval 0.7-0.9), P < 0.001]. The cut-off value for duration of illness was 16 days (sensitivity 94.4%, specificity 54.7%). The conversion group had a significantly greater need for postoperative intensive care unit stay (P = 0.022) but a lower rate of reoperations (P = 0.105).CONCLUSIONS: Duration of illness and frank pus discovered during thoracocentesis can help in selecting the patient for appropriate intervention. Earlier surgery for pleural empyema can reduce the rate of conversion and reoperation.
Only 1% to 2% of meningiomas have primary extrameningeal location, which is mostly head and neck region. Primary pulmonary meningiomas (PPMs) are even more uncommon with up to 50 cases reported in the literature. Only 5 cases of PPM with confirmed or possible malignancy have been previously described. Three-grade classification of meningiomas with the accordingly growing risk of aggressive behavior of the tumor has been proposed by the World Health Organization. As it is based on correlations between morphological and clinical features of intracranial meningiomas, the analogous prediction of ectopic tumors prognosis remains questionable due to scarce number of cases. In this article, we present a rare case of PPM with rhabdoid features (World Health Organization grade III), which lacked other signs of malignancy. The patient is doing well for 2 years after the thoracoscopic wedge resection without evidence of the disease recurrence.
Descending necrotizing mediastinitis is a severe infection spreading from the cervical region to the mediastinum. Since this pathology is uncom mon, only a few reports of large series of patients with descending nec rotizing mediastinitis have been published. The present aim was to eval uate our treat ment strategy and survival for this disease by a retrospective chart review. Methods. Retrospective analysis of 45 cases with descending necrotizing mediastinitis was performed between 2002 and 2011. The mean age was 55.3 ± 15.4 years. The primary oropharyngeal infection was found in 16 (35.6%), an odontogenic abscess in 17 (37.7%) and other causes in 12 (26.7%) patients. Endo type I mediastinitis was assessed in 25 (56%) patients, Endo type IIA in 10 (22%) and Endo type IIB in 10 (22%) patients. Broad spectrum antibiotics were administered empirically and surgical treatment consisting of cervical drainage, thoracotomy with radical surgical debridement of the mediastinum and placement of permanent mediastinal irrigation were performed in all the cases. Results. Collar incision and drainage only were performed in 16 (35.6%) patients, whereas only transthoracic approach was used in five cases (11%). In the remaining 24 (53.4%) patients cervical drainage and thoracic operation were performed. Fifteen patients had severe complications: septic shock, multiple organ failure and haemorrhage from mediastinal vessels. The median hospital stay was 21 days. The outcome was favourable in 35 patients. Ten patients died (overall mortality 22.2%). There was a negative correlation between the time from the onset of symptoms till the first admittance to hospital and hospitalization time (Pearson correlation coefficient 0.357, p = 0.016). That allows us to suggest that time of illness spent at home without appropriate treatment plays a crucial role on the survival. It was found that younger age, Endo type I, negative bacterial culture and longer hospital stay are true precursors of favourable outcome. Conclusions. For descending necrotizing mediastinitis limited to the upper part of the mediastinum a transcervical approach and drainage may be sufficient. However, in advanced cases an immediate and more aggressive surgical approach is required to combat a much higher morbidity and mortality in this subset of patients.
Acute myocardial infarction caused by a bronchogenic cyst is a very rare pathology. It occurs as a result of external compression of the coronary artery by the cyst, leading to myocardial ischemia. The present case illustrates that a bronchogenic cyst, which is generally considered to be a chronic disease entity with gradual onset of symptoms, can manifest acutely as a life-threatening condition. Timely invasive coronary intervention is critical in the acute management of this complication while multimodality imaging assessment is essential in the subsequent management of the underlying etiology.
Įvadas / tikslasPleuros empiema – viena iš seniausiai žinomų krūtinės ligų ir iki šiol yra susijusi su didėjančiu sergamumu visame pasaulyje. Kaip ir daugelyje chirurgijos sričių, gydant pūlinėmis pleuros ligomis sergančius ligonius populiarėja minimaliai invazinės chirurginės procedūros. Tačiau torakoskopinė operacija vis dar negali pakeisti atvirosios visais empiemų atvejais. Šiame straipsnyje supažindiname su mūsų atliekamų torakoskopinių pleuros empiemos operacijų metodika ir aptariame pradinę patirtį.Ligoniai ir metodaiNuo 2011 m. sausio iki 2013 m. rugsėjo torakoskopiškai buvo operuoti 49 ligoniai, sergantys pleuros empiema. Visi pacientai operuoti sukėlus bendrinę nejautrą, naudojant vieno plaučio ventiliaciją. Visos torakoskopinės operacijos buvo padarytos per dvi arba tris angas krūtinėje. Tais atvejais, kai sėkmingai atlikti torakoskopiniu būdu empiemektomijos nepavykdavo, būdavo pereinama į atvirąją (torakotominę) operaciją.RezultataiSėkmingai videotorakoskopinė operacija buvo atlikta 36 (73,5 %) ligoniams, o 13 (26,5 %) atvejų prireikė konversijos į atvirą operaciją. Pleuros ertmės sąaugos ir negalėjimas iki galo pašalinti ant plaučio paviršiaus susidariusio jį kaustančio šarvo buvo pagrindinės konversijų priežastys. Dešimt (20 %) ligonių patyrė tokių pooperacinių komplikacijų kaip ligos atkrytis, ilgesnį laiką besiskiriantis pro drenus oras, žaizdos infekcija.IšvadosPleuros empiemos atveju minimaliai invazinė chirurgija yra saugi ir pakankamai efektyvi. Tačiau turėtume ieškoti tam tikrų veiksnių, kurie padėtų atrinkti asmenis, tinkamus sėkmingai torakoskopinei pleuros empiemos operacijai.Reikšminiai žodžiai: pleuros empiema, piotoraksas, videoasistuojamoji krūtinės chirurgija, empiemektomija, dekortikacija Successful video-assisted thoracic surgery for pleural empyemaŽymantas Jagelavičius, Vytautas Jovaišas, Algis Kybartas, Arūnas Žilinskas, Lina Lukoševičiūtė, Ričardas Janilionis, Narimantas Evaldas Samalavičius Background / ObjectiveFew thoracic conditions present such a considerable challenge as does pleural empyema. The disease is known since Hippocrates’ time, nonetheless it is still associated with the rising incidence all over the world. Minimally invasive procedures become more and more popular in many fields of surgery as well as in patients with pleural empyema. However, video-assisted thoracoscopy cannot replace open surgery in all empyema cases. In this report, we would like to present our thoracoscopic technique and preliminary experience in treating patients with pleural empyema.Patients and methodsDuring the period from January 2011 till September 2013, thoracoscopic empyemectomy was performed in 49 patients. All patients were operated on under general anaesthesia using single lung ventilation. All procedures were performed through two or three ports. Conversion to thoracotomy was performed when it was impossible to make successfully thoracoscopic empyemectomy.ResultsA video-assisted thoracoscopic operation was successful in 36 (73.5%) patients, whereas in 13 (26.5 %) cases a conversion was required. Pleural space adhesions and inability to remove completely the peel from the underlying lung were the main reasons for conversion. Ten (20%) patients had postoperative complications such as recurrence of disease, prolonged air leak, or wound infection.ConclusionsMinimally invasive surgery is a safe and effective treating of patients with pleural empyema. However, we should search for preoperative factors of identifying the right persons who could be cured successfully by video-assisted thoracoscopic surgery.Key words: pleural empyema, pyothorax, video-assisted thoracic surgery, empyemectomy, debridement, decortication
A 52-year-old male was admitted to the Department of General Thoracic Surgery with a right-side localized pyopneumothorax that showed no improvement after conservative treatment. Open-window thoracostomy was created due to the presence of bronchopleural fistula. The capacity of the cavity was 600 ml. On the 11th postoperative day, a spontaneous closure of the bronchopleural fistula occurred. Later, a vacuum-assisted device was used for the residual empyema cavity treatment. It was used for 15 days, sponges were changed every 5 days. The residual cavity reduced in size six times (till 100 ml). The patient was discharged for a daily dressing changing at the outpatient department. After two months the patient was ready for a radical closure of open-window thoracostomy. The postoperative period was uneventful. The case shows that the vacuumassisted closure therapy can be safely used in open-window thoracostomy after pleural empyema. This method reduces the duration of open-window thoracostomy and accelerates surgical closure. Key words: pleural empyema, pyopneumothorax, VAC therapy, open window thoracostomyPenkiasdešimt dvejų metų vyras dėl dešinio riboto piopneumotorakso buvo hospitalizuotas į Krūtinės chirurgijos skyrių, nes konservatyvus gydymas buvo neveiksmingas. Dėl persistuojančios bronchopleurinės jungties padaryta pleurostoma. Vienuoliktą pooperacinę parą bronchopleurinė jungtis savaime išnyko, todėl buvo nuspręsta naudoti vakuuminę žaizdų gydymo sistemą. Aktyvios aspiracijos sistema per sidabru impregnuotą kempinę naudota 15 dienų (kempinės keistos kas penkias dienas). Po šio gydymo kurso pleurostomos tūris sumažėjo nuo 600 ml iki 100 ml. Pacientas išrašytas gydytis ambulatoriškai. Po dviejų mėnesių ertmė buvo sumažėjusi iki 10 ml, visiškai epitelizavosi ir buvo tinkama torakoplastinei operacijai. Gydant pleuros empiemą, kuri komplikavosi piopneumotoraksu, galima sėkmingai naudoti vakuuminę žaizdų gydymo sistemą. Šis gydymo metodas sutrumpina liekamosios pleuros ertmės egzistavimą ir leidžia greičiau atkurti krūtinės sienos vientisumą. Reikšminiai žodžiai: pleuros empiema, piopneumotoraksas, vakuuminė žaizdų gydymo sistema, pleurostoma
Background. Empyema remains a challenging entity for thoracic surgeons. The aim of this study was to evaluate preoperative predictors for unsuccessful thoracoscopic empyemectomy and postoperative complications.Materials and methods. There were 71 patients prospectively included in the study during the period from January 2011 to June 2014 in whom we performed thoracoscopic empyemectomy. Two main outcomes were evaluated: conversion and complications. Preoperative factors that could predict these outcomes were analyzed.Results. Conversion to open thoracotomy was required in 25.4% of cases. Fourteen (19.7%) patients had postoperative complications. The multivariate analysis showed that the time of illness (odds ratio 1.1; confidence interval 1.1-1.2), normal temperature on admission (odds ratio 11.2; confidence interval 1.5-85.4) and frank pus found on thoracocentesis (odds ratio 6.9; confidence interval 1.6-29.4) had a significant influence on conversion from thoracoscopy to open thoracotomy. Pain (odds ratio 0.01; confidence interval <0.01-0.6), subfebrile temperature on admission (odds ratio 10.1; confidence interval 1.4-73.5), positive pleural culture (odds ratio 8.5; confidence interval 1.0-70.1), Charlson comorbidity index (odds ratio 2.3; confidence interval 1.1-4.8), empyema volume (odds ratio 1.002; confidence interval 1.000-1.005) and empyema density (odds ratio 0.8; confidence interval 0.6-1.0) had a significant influence on postoperative complications.Conclusions. Longer time of illness, normal temperature on admission and frank pus in pleural aspiration increase probability of conversion. No pain, subfebrile temperature, higher Charlson comorbidity index on admission, positive pleural culture, higher volume and lower density of empyema on computed tomography scan increase probability of postoperative complications.
Įvadas / tikslasPleuros empiema – viena iš seniausiai žinomų krūtinės ligų ir iki šiol yra susijusi su didėjančiu sergamumu visame pasaulyje. Kaip ir daugelyje chirurgijos sričių, gydant pūlinėmis pleuros ligomis sergančius ligonius populiarėja minimaliai invazinės chirurginės procedūros. Tačiau torakoskopinė operacija vis dar negali pakeisti atvirosios visais empiemų atvejais. Šiame straipsnyje supažindiname su mūsų atliekamų torakoskopinių pleuros empiemos operacijų metodika ir aptariame pradinę patirtį.Ligoniai ir metodaiNuo 2011 m. sausio iki 2013 m. rugsėjo torakoskopiškai buvo operuoti 49 ligoniai, sergantys pleuros empiema. Visi pacientai operuoti sukėlus bendrinę nejautrą, naudojant vieno plaučio ventiliaciją. Visos torakoskopinės operacijos buvo padarytos per dvi arba tris angas krūtinėje. Tais atvejais, kai sėkmingai atlikti torakoskopiniu būdu empiemektomijos nepavykdavo, būdavo pereinama į atvirąją (torakotominę) operaciją.RezultataiSėkmingai videotorakoskopinė operacija buvo atlikta 36 (73,5 %) ligoniams, o 13 (26,5 %) atvejų prireikė konversijos į atvirą operaciją. Pleuros ertmės sąaugos ir negalėjimas iki galo pašalinti ant plaučio paviršiaus susidariusio jį kaustančio šarvo buvo pagrindinės konversijų priežastys. Dešimt (20 %) ligonių patyrė tokių pooperacinių komplikacijų kaip ligos atkrytis, ilgesnį laiką besiskiriantis pro drenus oras, žaizdos infekcija.IšvadosPleuros empiemos atveju minimaliai invazinė chirurgija yra saugi ir pakankamai efektyvi. Tačiau turėtume ieškoti tam tikrų veiksnių, kurie padėtų atrinkti asmenis, tinkamus sėkmingai torakoskopinei pleuros empiemos operacijai.Reikšminiai žodžiai: pleuros empiema, piotoraksas, videoasistuojamoji krūtinės chirurgija, empiemektomija, dekortikacija Successful video-assisted thoracic surgery for pleural empyemaŽymantas Jagelavičius, Vytautas Jovaišas, Algis Kybartas, Arūnas Žilinskas, Lina Lukoševičiūtė, Ričardas Janilionis, Narimantas Evaldas Samalavičius Background / ObjectiveFew thoracic conditions present such a considerable challenge as does pleural empyema. The disease is known since Hippocrates’ time, nonetheless it is still associated with the rising incidence all over the world. Minimally invasive procedures become more and more popular in many fields of surgery as well as in patients with pleural empyema. However, video-assisted thoracoscopy cannot replace open surgery in all empyema cases. In this report, we would like to present our thoracoscopic technique and preliminary experience in treating patients with pleural empyema.Patients and methodsDuring the period from January 2011 till September 2013, thoracoscopic empyemectomy was performed in 49 patients. All patients were operated on under general anaesthesia using single lung ventilation. All procedures were performed through two or three ports. Conversion to thoracotomy was performed when it was impossible to make successfully thoracoscopic empyemectomy.ResultsA video-assisted thoracoscopic operation was successful in 36 (73.5%) patients, whereas in 13 (26.5 %) cases a conversion was required. Pleural space adhesions and inability to remove completely the peel from the underlying lung were the main reasons for conversion. Ten (20%) patients had postoperative complications such as recurrence of disease, prolonged air leak, or wound infection.ConclusionsMinimally invasive surgery is a safe and effective treating of patients with pleural empyema. However, we should search for preoperative factors of identifying the right persons who could be cured successfully by video-assisted thoracoscopic surgery.Key words: pleural empyema, pyothorax, video-assisted thoracic surgery, empyemectomy, debridement, decortication
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