Usefulness of biodegradable absorbable rib connecting pins in thoracoabdominal hepatectomy

BACKGROUND/AIMS: Some patients who undergo thoracoabdominal hepatectomy suffer from pain and discomfort after because rib and/or costal cartilage was cut during the operation. The usefulness of absorbable rib connecting pins in thoracoabdominal hepatectomy was evaluated. METHODOLOGY: Of 18 patients who underwent thoracoabdominal hepatectomy, the stumps of ribs were not fixed in 9 patients (group 1) and the stumps of ribs were fixed with the rib connecting pins in 9 other patients (group 2). We evaluated the usefulness of these pins in thoracoabdominal hepatectomy. RESULTS: In 8 patients in group 1 and 2 patients in group 2, pain continued for 1 month after the operation (p = 0.015). At 2 months after the operation, pain continued in 6 patients in group 1 and no patients in group 2 (p = 0.009). At 6 months after the operation, 2 patients in group 1 still had pain. Rib instability continued in 8 patients in group 1 at 6 months after the operation, although rib instability disappeared by 2 months after the operation in all group 2 patients (p = 0.0004). CONCLUSIONS: Biodegradable absorbable pins for rib fixation are useful for preventing pain and discomfort around the cut stumps of ribs in thoracoabdominal hepatectomy.     

Clinical application of biodegradable rib connecting pins in thoracotomy.

BACKGROUND: To assess the usefulness in rib reconstruction of biodegradable connecting pins made of polylactide (PLA), PLA rib pins were compared with conventional non-absorbent aluminous ceramic rib pins (alumina rib pins) in terms of their ability for fixing and healing of cut ribs in thoracic surgery. METHODS: There were 13 cases of rib fixation after thoracotomy using PLA rib pins and 11 cases using alumina rib pins, all of which were inserted into the medulla of the stump of the ribs that had been cut at thoracotomy to secure a larger surgical field. The observation period was 6 months after the operation. RESULTS: The degree of vertical shift of the ribs connected with PLA rib pins was significantly reduced compared with the degree using alumina rib pins. In chest radiographs clear zones around the pins, indicating a delay in bone neogenesis, were observed frequently around the alumina rib pins but were absent around the PLA rib pins. Osteosynthesis using PLA rib pins was significantly more favorable than with alumina rib pins. CONCLUSIONS: These results demonstrated that the PLA rib pin was superior to the alumina rib pin for fixing and healing of the cut rib.     

Transcutaneous electric nerve stimulation for the treatment of postthoracotomy pain: a randomized prospective study

BACKGROUND: Insufficient relief of postthoracotomy pain is a major cause of increased rates of postoperative complications including inadequate coughing, mucous plugging, hypoxia, compromised ventilation or even bacterial lung infection. We aimed to assess the efficacy of transcutaneous electric nerve stimulation (TENS) in patients with postthoracotomy pain. METHODS: Forty patients scheduled to undergo posterolateral thoracotomy were randomly allocated to receive either TENS or patient-controlled intravenous morphine. Postoperative pain was evaluated using a visual analogue scale (VAS) and the Prince Henry pain scale. Pulmonary function was evaluated and an intergroup comparison was done. RESULTS: On the first three days following surgery, the VAS intensity of the TENS group did not differ significantly from that of the morphine group ( P > 0.05), and on the first two days following thoracotomy, the Prince Henry scale of the TENS group was not statistically significantly different. However, the VAS intensity was significantly lower than that of the control group on the fourth ( P = 0.044), fifth ( P = 0.016), sixth ( P = 0.009), seventh ( P = 0.008), eighth ( P = 0.004), ninth ( P = 0.002), tenth ( P = 0.001), fifteenth ( P = 0.002), thirtieth ( P < 0.001), forty-fifth ( P < 0.001) and sixtieth ( P < 0.001) days. The Prince Henry scale of the TENS group was found to be significantly diminished from the 3rd to the 60th day. TENS significantly reduced the analgesic requirements from day 5 to 60 ( P < 0.01). No noticeable side effect was observed in the TENS group during the study period. CONCLUSION: This study demonstrated that TENS provided a better pain relief and comfort compared to PCA from the fourth postoperative day onwards, and this pain-reducing effect continued for at least two months postoperatively.     

Breathing patterns during vaso-occlusive crisis of sickle cell disease

STUDY OBJECTIVES: To determine the effect of sickle cell pain and its treatment on patients' breathing patterns, and to compare the effect of thoracic cage pain to pain at other sites. DESIGN: Prospective, observational study. SETTING: Sickle Cell Center Day Hospital. PATIENTS: Twenty-five patients with sickle cell disease admitted to the Sickle Cell Center Day Hospital for treatment of vaso-occlusive crisis (VOC) [10 patients with chest (thoracic cage) pain]. INTERVENTIONS: Breathing patterns were measured by respiratory inductive plethysmography. Tidal breathing data, including respiratory rate, tidal volume (VT), minute ventilation, and the rib cage contribution to VT, were collected at baseline and then following treatment with opioid analgesia. MEASUREMENTS AND RESULTS: The patients with chest pain had smaller V(Ts) at baseline than those with pain at other sites (355 +/- 37 mL vs 508 +/- 141 mL, p = 0.003), and higher respiratory rates (23.2 +/- 8.2 breaths/min vs 17.6 breaths/min, p = 0.03). These differences became insignificant following opioid treatment. Six patients had respiratory alternans (four patients in the chest pain group, and two patients with pain at other sites). All cases of respiratory alternans resolved following opioid administration. CONCLUSIONS: Patients with VOC and chest pain have more shallow, rapid breathing than patients with pain elsewhere. Analgesia reduces these differences. As pain-associated shallow breathing and maldistribution of ventilation may contribute to the pathogenesis of acute chest syndrome, these results support the need for adequate pain relief and monitoring of ventilatory patterns during the treatment of VOC.     

A comparative evaluation of thoracic and lumbar epidural fentanyl for post thoracotomy pain

Thirty patients undergoing closed mitral valvotomy were prospectively randomised to receive either thoracic or lumbar epidural catheter. General anaesthesia consisted of morphine sulphate 0.15 mg/kg (single dose given before skin incision), thiopentone sodium 4-6 mg/kg, vecuronium and halothane titrated to stable haemodynamics. In the immediate postoperative period, pain was assessed by VAS (visual analogue scale) and VRS (verbal ranking score) and an epidural fentanyl bolus of 1.5 microg/kg was given followed by an infusion of 0.4 microg/kg/hr. Pain was assessed after 30 min and if pain relief was still inadequate, another fentanyl bolus of 1 microg/kg was administered, followed by an increase in infusion rate to 0.6 microg/kg/hr. If two consecutive pain scores were satisfactory (VAS <4, VRS <1) maintenance dose of fentanyl was decreased by 0.2 microg/kg/hr. Thoracic group received significantly less total dose of fentanyl in 24 hrs period (446.7 +/- 101.70microg) compared with the lumbar group (705.33 +/- 181.03microg) (p<0.01). The mean infusion rate was also significantly less in the thoracic group as compared with the lumbar group (0.44 +/- 0.08microg/kg/hr vs 0.61 +/- 11microg/kg/hr, p<0.001). The side effects were comparable between both the groups and none of the patients had significant respiratory depression. The data suggest that thoracic epidural fentanyl infusion is superior to lumbar infusion for post thoracotomy pain relief because of smaller dose requirement.     

Anterior limited thoracotomy with intrathoracic illumination for lung cancer: its advantages over anteroaxillary and posterolateral thoracotomy

STUDY OBJECTIVE: We developed anterior limited thoracotomy (ALT) with intrathoracic illumination for curative resection of lung cancer. The present study evaluated the benefits of ALT by retrospective comparison with anteroaxillary thoracotomy (AAT) and posterolateral thoracotomy (PLT). DESIGN: Lung cancer patients, who underwent lobectomy via ALT (n = 28), AAT (n = 28), and PLT (n = 28), were matched by gender and age. Operating time, blood loss during operation, chest tube drainage volume 24 h after surgery, chest tube drainage duration, and vital capacity (VC) and chest pain from early to late postoperative period were studied for ALT, AAT, and PLT. Early postoperative chest pain was evaluated by a visual analog scale and analgesic requirements, and chronic pain was divided into five grades. RESULTS: No difference was observed in operating time among ALT, AAT, and PLT. ALT has the following advantages over PLT: (1) less blood loss during surgery (p < 0.05); (2) reduced postoperative drainage volume (p < 0.05) resulting in shorter chest tube drainage (p < 0.001); (3) diminished impairment of VC for 1 week to 6 months after surgery (p < 0.01 or p < 0.001); and (4) reduced pain from 1 day and 6 months after surgery (p < 0.001). ALT also has the advantage over AAT in reduced pain 5 days (p < 0.01) and 7 days (p < 0.05) after surgery and in decreased analgesic requirements during 14 days after surgery (p < 0.05). CONCLUSION: ALT is a sufficient and minimally invasive thoracotomy alternative to PLT or AAT for curative lung cancer resection.     

Abnormal cortical pain processing in patients with cardiac syndrome X.

AIMS: Previous studies suggested that an enhanced pain sensitivity is present in patients with cardiac syndrome X (SX). We investigated whether SX patients present abnormalities in the electrical cerebral signals generated by pain stimuli. METHODS AND RESULTS: Cortical laser evoked potentials (LEPs) were recorded in 16 SX patients, in 10 patients with refractory angina due to obstructive coronary artery disease (CAD) and in 13 healthy controls. LEPs were recorded during stimulation of chest and right hand dorsum. Three sequences of painful stimuli were applied at each site. Subjective pain rating was assessed by a 0-100 mm visual analogic scale (VAS). Basal LEPs did not differ among groups and there were no differences for most LEP components across the repetitions of stimuli. However, the amplitude of the N2/P2 LEP component, specifically reflecting cortical pain processing, decreased across the three sequences of stimuli in controls and CAD patients, but not in SX patients. Compared with the first sequence, the N2/P2 amplitude during the third sequence of stimuli in the three groups was 77+/-16, 56+/-24, and 99+/-34%, respectively, for chest (P=0.001), and 63+/-31, 72+/-17, and 98+/-46%, respectively, for right hand (P=0.03) stimulation. The changes in VAS pain score across the three sequences paralleled those of N2/P2 amplitude. CONCLUSION: Our data show that in SX patients, central handling of painful stimuli is characterized by inadequate habituation, which might play a role in determining the peculiar clinical characteristics of anginal chest pain of these patients.     

The relationship between chest pain during thallium-201 scintigraphy with dipyridamole and myocardial ischemia

Dipyridamole thallium-201 scintigraphy (DP-Tl) and coronary angiography were studied on 74 patients with suspected coronary artery disease. We compared the clinical features, hemodynamic responses, angiographic results and scintigraphic findings of patients who had chest pain during DP-Tl testing ('chest pain' group) with those of patients who did not have chest pain ('no pain' group). Thirty eight (51%) of the 74 patients developed chest pain. Heart rate and rate pressure product during DP infusion of 'chest pain' group were greater than those of the 'no pain' group (p less than 0.05). Ischemic ST depression was more frequently observed among 'chest pain' patients (p less than 0.01). There were no differences in angiographic severity of coronary artery disease between 'chest pain' and 'no pain' group. Also, we could find no differences in extent and severity scores of perfusion defects and washout abnormalities between the two groups. However, when patients with myocardial infarction were excluded, the 'chest pain' group had significantly greater extent and severity scores of washout abnormalities than the 'no pain' group (extent score: 38 +/- 8 vs 18 +/- 5, p less than 0.05, severity score: 55 +/- 15 vs 18 +/- 7, p less than 0.01). Our study indicated that in patients without myocardial infarction, patients with 'chest pain' had more severe ischemia than 'no pain' patients. But in patients with myocardial infarction, myocardial ischemia not accompanied by chest pain might be as severe as that with chest pain. The presence or absence of myocardial infarction might have great influence on results regarding the relation of chest pain to myocardial ischemia.     

Pathophysiology of chest pain in patients with nutcracker esophagus

OBJECTIVES: Nutcracker esophagus is a manometric pattern that is commonly seen in patients with functional (noncardiac) chest pain. However, this pattern is often unassociated with pain. Consequently, the pathophysiology of chest pain in these patients is unclear. METHODS: We prospectively examined the sensory perception and biomechanical properties of the esophagus in 10 patients with chest pain and a nutcracker esophagus, along with those properties in 12 healthy controls using impedance planimetry. RESULTS: Stepwise balloon distentions reproduced typical chest pain in 9/10 (90%) patients. The threshold for chest pain was lower (p < 0.05) in patients than in controls (mean +/- SD 43+/-5 vs 62+/-4 cm H2O) but only 2/12 controls experienced pain. The thresholds for first perception and moderate discomfort were also lower (18+/-8 vs 30+/-11 cm H2O, p < 0.01 and 28+/-9 vs 62+/-5 cm H2O, p < 0.001) in patients than in controls, but only 3/12 controls experienced moderate discomfort. The esophageal reactivity to balloon distention was higher in patients than in controls (p < 0.001). The tension-strain curve shifted to the left in the patient group when compared to that in the controls (p < 0.05). CONCLUSIONS: Patients with a nutcracker esophagus demonstrate a hypersensitive and stiff esophagus. Because balloon distention reproduced their chest pain, visceral hyperalgesia of the esophagus may be relevant to the pathogenesis of their pain. Balloon distention test may be more useful in the evaluation of patients with functional chest pain and a nutcracker esophagus.     

Platelet contractile force (PCF) and clot elastic modulus (CEM) are elevated in diabetic patients with chest pain.

AIMS: Platelet function and clot structure may be altered in diabetes. We have noted increased platelet contractile force (PCF) and clot elastic modulus (CEM) in patients presenting to the emergency department with chest pain. Twenty-six of the chest pain patients were diabetic. Here, we compare the PCF, CEM and platelet aggregation in diabetic chest pain patients, non-diabetic patients with chest pain and asymptomatic controls. PATIENTS AND METHODS: PCF, CEM and collagen whole blood aggregations were measured in 100 chest pain patients and 25 asymptomatic controls. RESULTS: Platelet concentrations for diabetic patients, non-diabetic patients and controls were identical. PCF was significantly (P < 0.05) elevated in diabetic chest pain patients (9.42 +/- 0.59 kdynes) vs. controls (7.40 +/- 0.32 kdynes). CEM in diabetic patients (29.96 +/- 2.19 kdynes/cm2) was significantly elevated relative to that in non-diabetic chest pain patients (25.22 +/- 0.84 kdynes/cm2) and normal controls (23.18 +/- 0.74 kdynes/cm2). Collagen-induced whole blood aggregation was decreased (P < 0.05) in diabetic chest pain patients vs. controls. PCF values (10.23 +/- 0.76 kdynes) in diabetic patients with haemoglobin A1c > 7% were higher than in any other group. CONCLUSION: PCF and CEM are elevated in diabetic chest pain patients. The significance of these laboratory findings awaits additional clinical studies.     

Treatment of multiple rib fractures. Randomized controlled trial comparing ventilatory with nonventilatory management

We studied the treatment of multiple rib fractures in NIC, comparing ventilatory with nonventilatory methods in 69 patients who were randomly allocated to one of the following two treatments: (1) a CPAP mask combined with regional analgesia (n = 36); or (2) endotracheal intubation and mechanical ventilation with PEEP (n = 33). Clinical outcome was as follows: mean duration of treatment, 4.5 +/- 2.3 days for the group with CPAP and 7.3 +/- 3.7 days for the intubated group (p = 0.0003); mean number of days spent in intensive care, 5.3 +/- 2.9 days and 9.5 +/- 4.4 days, respectively (p = less than 0.0001); mean period of hospitalization, 8.4 +/- 7.1 days and 14.6 +/- 8.6 days, respectively (p = 0.0019); and patients developing complications: 28 percent (10/36) and 73 percent (24/33), respectively. Infections caused the difference in complications, primarily pneumonias, which occurred in 14 percent (5/36) of the group with CPAP but in 48 percent (16/33) of the intubated group. We conclude that treatment with a CPAP mask combined with regional analgesia can shorten and simplify treatment in these patients, mainly through a decreased infection rate, when compared with intubation and mechanical ventilation, and we recommend this treatment in patients similar to our sample.     

The time course of recovery following mild thoracic trauma

PURPOSE: The purpose of this study was to determine when patients are able to return to their normal work or home activities. PATIENTS AND METHODS: Eighty cases, 35 females (44%) and 45 males (56%), presenting to our hospital between the years of 2003 and 2004 were prospectively evaluated. There were no hemopneumothorax or associated injury. The patients were randomized into two groups with respect to treatment modalities as the following: non-steroid anti-inflammatory (NSAIDs) and Tramadol treatment groups. In the follow-up, visual analog scale (VAS), and vital capacity were conducted on the days 0, 2, 7 and 30 and 6 months. The results were statistically analyzed. RESULTS: The mean age of the group receiving NSAIDs was 55.42 +/- 15.72, and for the group receiving tramadol treatment, it was 55.67 +/- 17.23. VAS result was 7.8 +/- 1.8 in those receiving NSAIDs treatment, while it was 8.2 +/- 1.6 in the other group. The vital capacity was 235.54 +/- 82 ml for the former group, and 232.43 +/- 89.44 for the latter. In their follow-up, particularly by the 7th day, significant improvement of VAS and vital capacity were observed (p < 0.01). Maximum improvement was achieved on the 30th day (p < 0.001). There was no change in the 6th month. CONCLUSION: Patients are able to return to their normal work or home activities after 7 days. Patients experienced steadily decreasing pain and improved vital capacity at each time point after injury. No difference in response was seen between the two medications. A significant improvement is observed by the 7th day after the trauma (p < 0.01). Optimal improvement was achieved on the 30th day (p < 0.001).     

Intermittent injection vs patient-controlled analgesia for sickle cell crisis pain. Comparison in patients in the emergency department

BACKGROUND.--The purpose of this study is a prospective assessment of morphine sulfate administration by intermittent intravenous (IV) injections (Int-IV) vs patient-controlled analgesia (PCA) in patients in the emergency department (ED) with sickle cell crisis pain. METHODS.--Patients were at bed rest and received intravenous hydration. Linear analog scale for pain intensity and verbal pain scale, level of alertness, and vital signs were assessed prior to therapy, every 60 minutes thereafter, and at the time of discharge from the ED. Patients were randomized to Int-IV or PCA. During phase 1, patients in the Int-IV group received morphine sulfate 4 mg IV every 30 to 60 minutes as necessary for a linear analog scale for pain intensity greater than 50 mm. The patients in the PCA group received morphine sulfate 2 mg bolus then 1.0 mg with a 6-minute lockout. During phase 2, patients in the Int-IV group received morphine sulfate 8 mg IV every 30 to 60 minutes as necessary for a linear analog scale for pain intensity greater than 50 mm. The patients in the PCA group received morphine sulfate 5 mg bolus then 2.7 mg with a 10-minute lockout. Data were analyzed by unpaired t test, general linear modeling, Mann-Whitney U test, and chi 2 test. RESULTS.--During phase 1, 10 patients (28.3 +/- 7.3 years) received Int-IV and 10 patients (33.9 +/- 12.5 years) received PCA. Treatment groups did not differ significantly regarding duration of pain, amount of morphine administered, linear analog scale for pain intensity, verbal pain scale, level of alertness, or vital signs except for a significantly lower final respiratory rate with Int-IV. In phase 2, 12 patients (28.4 +/- 5.6 years) received Int-IV and 13 patients (26.8 +/- 8.1 years) received PCA. The PCA groups had a significantly shorter elapsed time between onset of pain and treatment (7.3 +/- 6.5 hours) when compared with the Int-IV group (18 +/- 16.9 hours). Treatment groups did not differ significantly with respect to total amount of morphine administered, linear analog scale for pain intensity, verbal pain scale, vital signs, or level of alertness. The PCA group had a significant reduction in length of stay in the ED during phase 2 when compared with phase 1. The ED discharge rate and the incidence of side effects did not differ significantly between groups. CONCLUSION.--At both the low- and high-dose regimens, PCA is equally safe and effective and may be used in place of Int-IV administration of morphine in the ED treatment of sickle cell crisis pain.     

Serum tumour necrosis factor-alpha,interleukin-2 and interleukin-10 activation in stable angina and acute coronary syndromes

BACKGROUND: Dynamic instability of coronary atherosclerotic plaque results in the development of both unstable angina and myocardial infarction. The aim of the study was to investigate the dynamics of serum concentrations of tumour necrosis factor (TNF)alpha, interleukin (IL)-10, and IL-2 in patients with myocardial infarction (MI) and unstable angina (UA) as compared to stable angina (SA) patients and healthy volunteers. METHODS: A total of 189 patients with coronary artery disease (CAD) were studied: 100 patients with SA (class II/III according to CCS), 57 patients with UA (Braunwald class IIIB; determinations at 6, 24, and 48 h after chest pain), and 32 patients with MI (determinations at admission, on the 7th and 30th days after MI). Twenty healthy volunteers acted as controls. RESULTS: Serum TNFalpha levels were elevated in all CAD groups (SA: 17.3+/-4; UA: 18.7+/-4; MI: 22.0+/-3 pg/ml; p<0.001) in comparison to the controls (8.3+/-1.4 pg/ml). However, the highest values were characteristic of MI patients, especially values obtained at admission (p<0.01 versus SA and UA). Mean serum concentrations of IL-2 were significantly higher in patients with MI and UA (89.6+/-40; 87.0+/-24 pg/ml, respectively; p<0.01) when compared to SA and the control group (58.3+/-49; and 51.5+/-39, respectively). Serum IL-10 levels were also higher in MI and UA patients. Levels of IL-2 and IL-10 measured following chest pain in unstable patients, as well as their consecutive determinations in MI patients did not show any change dynamics, that is, they were persistently elevated. CONCLUSIONS: When compared to stable CAD and healthy subjects, acute coronary syndromes are associated with long-term increase of serum concentrations of pro- and anti-inflammatory cytokines. It seems likely that sudden CAD progression leading to acute coronary syndromes is triggered/accompanied by prolonged immune activation.     

Thoracoscopic decortication as first-line therapy for pediatric parapneumonic empyema. A case series

STUDY OBJECTIVES: Previous articles have promoted the early use of thoracotomy and decortication for refractory empyema. This study examines thoracoscopy and decortication at the time of initial chest tube placement in pediatric patients with parapneumonic empyema. DESIGN: We reviewed the medical records of 16 consecutive patients who were children with parapneumonic empyema. RESULTS: Thirteen children (group 1) underwent thoracoscopic decortication and tube thoracostomy as their initial operative procedures; 3 children (group 2) had tube thoracostomy alone. In both groups, chest tubes were removed prior to their discharge to home. The mean (+/- SD) operative time for thoracoscopy was 81 +/- 19 min with no complications. On average, chest tubes were removed by postoperative day 4. The mean time to discharge was 8.3 days. Two children eventually required lobectomy. The mean operative time for chest tube placement alone was 21 +/- 3 min. Children required chest tube drainage for an average of 12.3 days. The mean time to discharge was 16.6 days. Two patients required a total of five additional operative procedures, including two additional chest tube placements, two open decortications, and one lobectomy. CONCLUSIONS: Thoracoscopic decortication is effective in the early treatment of pediatric parapneumonic empyema. It facilitates visualization, evacuation, and mechanical decortication of the pleural space with no additional morbidity and may lead to reduced time for chest tube drainage, shorter hospitalization, and more rapid clinical recovery.     

Stabilization of flail chest by compression osteosynthesis--experimental and clinical results

It has been demonstrated that the impaired ventilatory parameters can be normalized after early stabilization of flail chest. Most methods for operative fixation, however, have given disappointing results and only plate fixation procedures have been effective. The experimental results of osteosynthesis with dynamic compression plates are presented and demonstrate the superiority of compression osteosynthesis in rib fractures. Compression osteosynthesis resulted in a primary fracture healing with stable fragments after 14 days, whereas conventional plate fixation techniques required a much longer time and showed secondary fracture healing. The benefits of compression osteosynthesis could also be demonstrated in 10 patients with traumatic flail chest. Osteosynthesis resulted in marked pain relief, immediate stabilization of the chest wall, and a shorter time of intubation. Not all fractured ribs need stabilization, dorsal fractures are well fixed by the strong erector muscles, and in the lateral position only ribs III to VII need to be considered. Reasonable stabilization may be achieved with fixation of every second rib. In patients with bilateral rib serial fractures subcutaneous implantation of one or 2 rib struts is recommended--good results were obtained in 12 patients. The indication for operative stabilization of flail chest should be restricted to: 1. Patients with severe ventilatory restriction due to chest wall paradox alone. 2. Flail chest combined with intra-thoracic lesions which require thoracotomy. 3. Flail chest combined with lesions which require a prone position for surgical exploration. 4. Respiratory distress patients when the unstable chest wall interferes with mechanical ventilation or with underlying organs.     

The effect of proton pump inhibitor on healing of post-esophageal variceal ligation ulcers

BACKGROUND/AIMS: Esophageal variceal ligation (EVL) is the most preferable method for controlling variceal bleeding. However, EVL is associated with complications such as hemorrhage, chest pain, dysphagia, and odynophagia due to post-EVL ulcers in the esophageal mucosa. The aim of this study was to assess the effect of proton pump inhibitor (PPI), pantoprazole on the healing of post-EVL ulcers. METHODS: Forty seven patients were randomly allocated into PPI group and control group. Patients in PPI group received 40 mg of pantoprazole intravenously for 3 days after EVL, then 40 mg of oral pantoprazole for 11 days consecutively. Control patients received intravenous and oral placebo. Endoscopic examinations were performed twice at 7+/-2 days and 14+/-2 days after EVL respectively. Clinical outcomes include the size of ulcers, symptoms reported by patients; chest pain, dysphagia, and odynophagia. RESULTS: Forty seven patients completed the 7 days protocol (PPI/control; 25/22), and twenty six patients completed the 14 days protocol (PPI/control; 16/10). Post-EVL ulcers in PPI group were significantly smaller than those in control group (7 days; 98.7 mm2/119.4 m2, 14 days; 32.3 m2/43.8 m2, p<0.01). No difference was observed between two the groups with respect to summations of symptom scores (p> 0.05). Nineteen patients (PPI/control; 9/10) did not complete the 14 days protocol due to patients' refusal and adverse outcomes, such as hepatic failure and sepsis with bleeding from post-EVL ulcer occurred in two patients of control group. CONCLUSIONS: PPI treatment following EVL may be effective in healing post-EVL ulcer.     

Short-term course and outcome of treatments of pleural empyema in pediatric patients: repeated ultrasound-guided needle thoracocentesis vs chest tube drainage

BACKGROUND: Several reports have suggested that early chest tube drainage (CTD) may not be necessary in the treatment of severe pleural empyema (PE) in pediatric patients if appropriate antibiotic therapy and supportive care are provided. OBJECTIVES: A prospective open study to compare the short-term course of two treatment protocols of severe PE in pediatric patients. STUDY DESIGN: One group of 32 patients was treated with early insertion of a chest tube for CTD, and a second group of 35 patients was treated by a repeated ultrasound-guided needle thoracocentesis (RUSGT). The severity of the empyema was assessed by chest radiograph, the amount of fluid drained, the number of days the patient had experienced a fever, and the duration of antibiotic treatment. RESULTS: No significant differences were found between the two groups (RUSGT vs CTD) in all of the following measurements: mean (plus minus SD) duration of a temperature > or = 39 degreesC, 6.2 +/- 2.4 vs 6.5 +/- 1.8 days, respectively; mean duration of a temperature > or = 38 degreesC, 9 +/- 3.9 vs 8.2 +/- 4.5 days, respectively; fluid drained, 35.1 + 23.8 vs 30 +/- 28.2 mL/kg, respectively; duration of antibiotic treatment, 30 +/- 13.2 vs 30.2 +/- 7.3 days, respectively; and length of hospitalization and home IV treatment, 22 +/- 7.6 vs 24.2 +/- 7.5 days, respectively. A failure to respond to treatment occurred in three patients in the RUSGT-treated group and in five patients in the CTD-treated group. The failure to respond occurred in the RUSGT-treated group only in those patients with very large empyemas that caused mediastinal deviation. CONCLUSION: The treatment of PE by RUSGT is as efficacious as CTD, unless PE causes mediastinal deviation.     

Comparison of analgesic efficacy of fentanyl and sufentanil for chest tube removal after cardiac surgery

Chest tube removal in the postcardiac surgical patients is a painful and distressful event. Fentanyl and sufentanil have not been used for pain control during chest tube removal in the postoperative period. We compared efficacy offentanyl and sufentanil in controlling pain due to chest tube removal. One hundred and forty one adult patients undergoing cardiac surgery were recruited in a prospective, randomized, double blind, placebo controlled study. Patients were randomized to receive either 2 microg/Kg fentanyl IV or 0.2 microg/Kg sufentanil IV or 2 ml isotonic normal saline, 10 min before removing chest tubes. Pain intensity was assessed by measuring visual analog scale pain score 10 minutes before removing chest tubes and 5 min and 20 min after removing chest tubes. Level of sedation, heart rate, arterial pressure, oxygen saturation, and respiratory rate were recorded by a blinded observer at the same time intervals. Mean pain intensity scores 10 minutes before removal of chest tubes infentanyl, sufentanil and control groups were 23.88+/-5.2, 25.10+/-5.39 and 23.64+/-6.10 respectively. The pain scores 5 minutes after chest tube removal were reduced to 20.11+/-6.9 (p<0.05) in the fentanyl group and 13.60+/-6.60 (p<0.05) in the sufentanil group, whereas in control group pain scores increased to 27.97+/-8.39 (p相似文献