Thoracoscopic sympathectomy: endobronchial anesthesia vs endotracheal anesthesia with intrathoracic CO2 insufflation

Purpose. To compare clinical advantages and hemodynamic and respiratory changes during one lung-collapsed ventilation (OLCV) using a double-lumen tube (DLT) or a single-lumen tube (SLT) with intrathoracic CO₂ insufflation, in patients undergoing thoracic sympathectomy (TS) under general anesthesia. Methods. One hundred and twenty-five patients (94 men and 31 women) undergoing TS for the treatment of palmar hyperhidrosis (PH) were randomly allocated to two groups: group A (68 patients; age, 29 ± 6 years) in whom DLT was used, and group B (57 patients; age, 32 ± 3 years) in whom SLT with intrathoracic CO₂ insufflation at a rate of 0.5–1 l·min⁻¹ and sustained intrathoracic pressure at 6 mmHg insufflation were used. Anesthesia was maintained with 1 minimum alveolar concentration (MAC) isoflurane in 50% nitrous oxide in oxygen with incremental doses of sufentanil and atracurium when required. Arterial blood gases were measured in 10 patients in group B. Hemodynamic and respiratory parameters were obtained perioperatively. Results. There were no significant differences in hemodynamic and respiratory parameters between the two groups during the study phases, except for the arterial oxygen saturation (SpO₂). The times required for anesthesia and surgery were significantly shorter in the SLT group than in the DLT group. SpO₂ during OLCV was 95 ± 1% with DLT and 98 ± 1% with SLT, with a significant difference. Three patients had an SpO₂ of less than 90% in the recovery room, where the chest tube position was readjusted, with no further sequelae. Conclusion. General anesthesia with SLT and intrathoracic CO₂ insufflation provides optimal operating conditions, adequate oxygenation, and perfect hemodynamic stability during TS. Received: November 28, 2000 / Accepted: August 8, 2001     

Pericarditis after trauma resulting in delayed cardiac tamponade

Pericarditis complicating cardiac trauma and resulting in tamponade is uncommon. Possible causes include an autoimmune reaction or an inflammatory response to blood entering the pericardium. We present two patients, one with effusive and one with constrictive pericarditis occurring within 2 weeks of a penetrating trauma close to but not directly involving the heart. These cases illustrate the importance of clinical suspicion and aggressive management in the diagnosis and management of such patients.     

Natural history of traumatic rupture of the thoracic aorta managed nonoperatively: a longitudinal analysis

BACKGROUND: Although traumatic rupture of the thoracic aorta (TRA) has traditionally been considered a surgical emergency, there exists a small patient population for whom nonoperative management may be appropriate. The short- and long-term consequences of patients managed in a nonoperative fashion remain unclear. METHODS: A review of patients admitted with TRA over a period of 16 years was performed. Patients who did not undergo operative repair within 24 hours of injury and diagnosis comprised the study group. RESULTS: One hundred forty-five patients were admitted with TRA. Of these, 30 underwent a period of nonoperative management. The mean age of the study patients was 44 +/- 21 years, 80% were male, and the mean Injury Severity Score (ISS) was 34 +/- 9. Fifteen patients underwent delayed operation (DELAY group) at more than 24 hours after injury and diagnosis and 15 patients never underwent repair (NON-OP group). The median time to operation in the DELAY group was 3 days (range 2 to 90). Three patients exhibited progression of TRA within 5 days of injury and of these, 2 died. A total of 3 deaths occurred in the DELAY group (1 rupture and 2 intraoperative arrests). The fifteen NON-OP patients were significantly older (mean age 52 +/- 22 versus 36 +/- 18 years; p = 0.03), tended to be more severely injured (mean ISS 36 +/- 9 versus 32 +/- 8; p = 0.2), and had more premorbid risk factors than the DELAY patients. Five NON-OP patients died, all because of severe head injuries. On long-term follow-up of NON-OP patients, all 10 survivors are alive at a median of 2.5 years (range 6 months to 5 years) without progression of injury or the need for operation. Five of the 10 had complete radiographic resolution of their injuries and 5 have asymptomatic and radiographically stable pseudoaneurysms. CONCLUSIONS: Selected patients with multiple severe associated injuries or high-risk premorbid conditions may have their operations for TRA delayed temporarily or even indefinitely with acceptable survival rates. The potential for rapid progression of TRA in the same patients, however, mandates serial radiographic examinations during the first week of hospitalization after injury and diagnosis.     

Nuclear chromatin patterns in 3 glucocorticoid-resistant RPMI 8226 human myeloma cell sub-lines: correlations with cell growth and immunological phenotype

Nuclear morphological alterations associated with glucocorticoid resistance in human myeloma were evaluated by image cytometry in three human myeloma RPMI 8226 cell sub-lines. Resistance was induced by drug selection using prednisone (8226p), methylprednisolone (8226m) and dexamethasone (8226d), respectively. All these three cell sub lines displayed significant glucocorticoid-resistance without cross-resistance to doxorubicin. Nuclear geometry and texture were analyzed on G0/G1-selected cell nuclei and data compared with cell growth characteristics and membrane expression of CD23, CD38, CD44 and CD58 antigens. When compared to the parental RPMI 8226 cell line, glucocorticoid-resistant cells display a progressive chromatin condensation with heterogeneously distributed large chromatin clumps, a phenomenon not observed in the multidrug-resistant CEM-VLB cells. These alterations were correlated to the resistance index against glucocorticoids and to the expressions of CD38, and of CD44 variant forms CD44v5 and CD44v7-8 antigens. These data suggest that glucocorticoid resistance in RPMI 8226 cells could be associated with sub-visual specific higher-order chromatin organization changes. Furthermore, these alterations are correlated to the expression of membrane markers associated with tumors aggressiveness.     

Management of the anticoagulated patient

Excessive bleeding or thrombosis is a preeminent concern for all surgeons. Patients may be at risk because of medical therapy, underlying disease, or complications related to both. An understanding of the coagulation cascade--mechanisms and tests of function--permits a rational, if not always complete, basis for a plan of therapy. Newer anticoagulation medications are changing how thrombotic complications, such a VTE or graft occlusion, are treated or prevented. This entire area is undergoing rapid evolution, and the approaches that have been standard for decades soon will be supplanted. Ultimately, however, the most important assessment is made at the bedside by the clinician.     

Ball-thrower’s fracture of the humerus

A relatively rare case of ball-throwers fracture of the humerus is presented. Severe muscular action is an uncommon cause of humeral fractures but has been well documented in the orthopedic literature. To our knowledge, this fracture has not been described in the radiology literature, and awareness of this entity could preclude further unnecessary workup. The mechanism of injury and its typical radiographic appearance is described.     

Endovascular stent grafts for acute blunt aortic injury

BACKGROUND: Endovascular stent grafting (EVSG) has emerged as a new treatment for aortic disease and has recently been applied to the treatment of acute blunt aortic injury (BAI). The purpose of this study was to determine the outcome of EVSG for patients with BAI at two tertiary (Level I) trauma centers. METHODS: A retrospective review of patients treated between January 1, 1999, and February 1, 2003, at two centers, Calgary Health Region (Calgary, Alberta) and Harborview Medical Center (Seattle, WA), with EVSG for acute BAI is reported. Variables assessed included age, sex, Injury Severity Score, total length of stay (LOS), intensive care unit LOS, operative technique, complications, technical success, mortality, and follow-up data. RESULTS: Twenty-eight patients treated with EVSG for BAI were identified during this period. Twelve patients were excluded because injuries occurred more than 30 days before grafting (n = 7) or under a different protocol (n = 4), or the procedure was performed in a different center (n = 1). Sixteen patients with acute BAI were reviewed. The mean Injury Severity Score was 36.9 (SD, 17.0), with a median intensive care unit LOS of 7.5 days (interquartile range, 1-17 days) and total LOS of 24.5 days (interquartile range, 7-41 days). Mean follow-up was 10.7 months (range, 3-30 months). Technical success was achieved in all patients, no graft-related complications have been detected during follow-up, and no patient developed postoperative paraplegia. One postoperative mortality occurred secondary to severe comorbid injury. A single patient with a preoperative traumatic carotid dissection demonstrated a postoperative stroke, and one patient required thoracentesis for a pleural effusion. CONCLUSION: Repair of BAI with EVSG can be performed safely in patients with BAI. Mortality, morbidity, and especially paraplegia are reduced. Further long-term studies are required to support the routine use of EVSG technology for BAI.