Surgical management of acute necrotizing lung infections

BACKGROUND:

Surgical resection for acute necrotizing lung infections is not widely accepted due to unclear indications and high risk.

OBJECTIVE:

To review results of resection in the setting of acute necrotizing lung infections.

METHODS:

A retrospective review of patients who underwent parenchymal resection between January 1, 2000, and January 1, 2006, for management of necrotizing pneumonia or lung gangrene.

RESULTS:

Thirty-five patients underwent resection for lung necrosis. At the time of consultation, all patients presented with pulmonary sepsis, and also had the following: empyema (n=17), hemoptysis (n=5), air leak (n=7), septic shock requiring pressors (n=8) and inability to oxygenate adequately (n=7). Twenty-four patients were ventilated pre-operatively. Eleven patients had frank lobar gangrene, and the other patients had combinations of necrotizing pneumonia and abscesses. In 10 patients, preresection procedures were performed, including percutaneous drainage of an abscess (n=4), thoracoscopic decortication (n=4) and open decortication (n=2). Procedures included pneumonectomy (n=4), lobectomy (n=18), segmentectomy (n=2), wedge resection (n=4) and debridement (n=7). There were three (8.5%) postoperative deaths – two due to multiple organ failure and one due to anoxic brain injury. All patients not ventilated preoperatively were weaned from ventilatory support within three days. Of those ventilated preoperatively, three died, while four remained chronically ventilator dependent.

CONCLUSIONS:

Surgical resection for necrotizing lung infections is a reasonable option in patients with persistent sepsis who are failing medical therapy. Ventilated patients have a worse prognosis but can still be candidates for resection. Patients who are hemodynamically unstable appear to have better outcomes if they can be stabilized before resection.     

Intradetrusor injection of botulinum toxin A in children: a 10-year single centre experience

International Urology and Nephrology - We evaluated the efficacy and safety outcomes of endoscopic intradetrusor botulinum toxin A (BTA) injections for the treatment of children with neuropathic...     

Anterior mediastinal abscess after closed sternal fracture.

BACKGROUND: Although sternal fractures after blunt chest trauma are markers for significant impact, the fracture itself is generally not associated with any specific wound complications. Mediastinal abscess and sternal osteomyelitis rarely occur after blunt trauma or cardiopulmonary resuscitation. Management of such complications is difficult, and requires a spectrum of operative procedures that range from simple closure to muscle flap reconstruction. METHODS: The trauma registry of a Level I trauma center was used to identify patients suffering a sternal fracture between January of 1994 and August of 1997. Records were reviewed for the mechanism of injury, length of hospital stay, and posttraumatic mediastinal abscess. RESULTS: Twenty-six patients were identified with sternal fracture. No clinically significant cardiac or aortic complications were noted. Three patients, all with a history of intravenous drug abuse and requiring central venous access in the emergency room, developed methicillin resistant Staphylococcus aureus mediastinitis. Sternal re-wiring and placement of an irrigation system successfully treated all three patients. CONCLUSION: Posttraumatic mediastinal abscess is an uncommon complication of blunt trauma in general and sternal fracture in particular. It can be recognized by the development of sternal instability. Risk factors include the presence of hematoma, intravenous drug abuse, and source of staphylococcal infection. Treatment with early debridement and irrigation can avoid the need for muscle flap closure.     

Descending thoracic aortic dissections

Type B dissection has traditionally been managed medically if uncomplicated and surgically if associated with complications. This practice has resulted in most centers reporting significant morbidity and mortality if open repair is required. In the setting of malperfusion, operative repair has been conjoined with fenestration or visceral stenting to improve outcomes. Endovascular stent grafts seem to offer an attractive alternative in the acute complicated type B dissection, with reduced mortality and morbidity, particularly paralysis, compared with open repair. It is reasonable to consider endovascular stent grafts as another tool in managing dissection, but to recognize that open surgical repair still plays an important role, and that the data that define indications and outcomes are still emerging.     

Emergency laparoscopic repair of a paraesophageal hernia

A 63-year-old male with a previously documented paraesophageal hernia presented with acute severe epigastric pain and bloating. He was taken urgently to the operating room for laparoscopic exploration. The hernia sac was reduced with difficulty owing to extensive adhesions and the incarcerated portion of the stomach was mottled and blue. After 10 min of observation the stomach began to resume a normal appearance. The anterior crura were approximated and an anterior gastropexy was performed. The patient was discharged on the 3rd postoperative day and has been asymptomatic since. Paraesophageal hernias with evidence of impending gastric necrosis can be approached laparoscopically as long as basic principles are observed.     

Results of a multi-institutional outcome assessment: results of a structured peer review of TRISS-designated unexpected outcomes.

The utility of TRISS as a component of trauma center quality assurance (QA) was evaluated. TRISS survival probabilities were estimated for a total of 2,023 consecutive trauma patients admitted to three level-I trauma centers during a 6-month period. A structured peer review was performed of the 50 patients (2.1%) having statistically unexpected outcomes. For 23 (18 survivors, five deaths) TRISS-designated outcomes were sustained in peer review. In 27 cases (one survivor, 26 deaths) TRISS-designated outcomes were not sustained by peer review and TRISS. Limitations were identified in each case. Peer review of unexpected outcomes identified by TRISS provided a consistent and objective QA methodology. An understanding of TRISS as an objective component of the trauma center QA process is essential in blending it with what is, at present, a largely subjective process in many hospitals. Use of TRISS standardizes the peer review process, resulting in a more reliable base for development and improvement of trauma center QA programs.     

Serodiagnosis and seroepidemiology of human unilocular hydatidosis in Jordan

A total of 2182 serum samples from 38 patients with surgically confirmed unilocular hydatidosis, 19 clinically assessed patients, 15 patients with parasitic infections other than hydatidosis, 104 hospital outpatients, and 2006 normal Jordanians were serodiagnosed for the presence of IgG antibodies against hydatid fluid, circulating immune complexes (CIC), and/or hydatid circulating antigen (CA). Anti-hydatid IgG antibodies were detected in the sera of 77.4% of patients with hydatid discase and persiste for very long periods postsurgery. As many as 54.1% of patients with hydatidosis had positive levels of CIC, and 16.1% had circulating antigen in their sera. The search for circulating antigen and CIC decreased the number of false-negative hydatid cases from seven to three, and the combined sensitivity of the assays thus increased from 77.4% to 90.3%. Using the immunoblot technique, 16- and <14.4-kDaEchinococcus granulosus-specific bands were detected in sera from 54.1% and 61.5% of patients with hydatid disease who were tested before and after surgery, respectively. The seropositivity rate for anti-hydatid IgG antibodies was 2.4% for the general Jordanian population and 5.8% for hospital outpatients.     

Changes in the oropharyngeal airway of Class II patients treated with the mandibular anterior repositioning appliance

Objective:To evaluate the effects of functional appliance treatment on the oropharyngeal airway volume, airway dimensions, and anteroposterior hyoid bone position of growing Class II patients.Materials and Methods:Twenty Class II white patients (mean age, 11.7 ± 1.75 years) treated with the MARA followed by fixed appliances were matched to an untreated control sample by cervical vertebrae maturation stage at pretreatment (T1) and posttreatment (T2) time points. Cone beam computed tomography scans were taken at T1 and T2. Dolphin3D imaging software was used to determine oropharyngeal airway volume, dimensions, and anteroposterior hyoid bone position.Results:Multivariate ANOVA was used to evaluate changes between T1 and T2. Oropharyngeal airway volume, airway dimensions, and A-P position of the hyoid bone increased significantly with functional appliance treatment. SNA and ANB decreased significantly in the experimental group (P ≤ .05). Changes in SNB and Sn-GoGn failed to reach statistical significance.Conclusions:Functional appliance therapy increases oropharyngeal airway volume, airway dimensions, and anteroposterior hyoid bone position in growing patients.