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Right pneumothorax occurred 2 days after laparoscopic-assisted vaginal hysterectomy. The mechanism was most likely CO2 diffusion from pneumoperitoneum through a diaphragmatic defect. It is essential to be aware of this rare complication because of its late onset after the surgical procedure.
BACKGROUND AND AIMS: Chest radiographs (CXRs) are performed routinely after permanent pacemaker implantation to identify pacemaker lead position and exclude pneumothorax. We assessed the clinical value and need for this procedure. DESIGN: Retrospective analysis of pacemaker data and CXRs following permanent pacemaker insertion between December 2002 and February 2004. MATERIALS AND METHODS: Post-procedural CXRs were available in 125/126 consecutive patients after either first endocardial pacemaker implantation or insertion of at least one new lead. Subclavian vein puncture was used for venous access in all cases. CXRs were examined to establish the incidence of pneumothorax and assess pacing lead positions. The clinical records were examined in all patients who had subsequent CXRs or a further pacemaker procedure to identify the indication for these and to establish whether CXR had influenced patient management. RESULTS: In total, 192 post-procedural CXRs were performed, either postero-anterior (PA) and/or lateral views. Ventricular and/or atrial pacing lead contour and electrode position was considered radiographically appropriate in 86% CXRs. Fourteen per cent of post-procedural radiographs were considered to have radiologically sub-optimal pacemaker lead positioning. None of the patients with these "abnormal" radiographs experienced subsequent pacemaker complications or had further radiographs recorded at a later date. Later repeat CXRs were performed in 16 patients (13%) but only 3 patients (2%) had pacing abnormalities as the primary indication. All three had satisfactory pacing lead position on initial post-implantation and later radiographs, but required further procedures for lead re-positioning. Iatrogenic pneumothorax occurred in one patient (incidence 0.8%) in our series. CXR confirmed the clinical diagnosis and allowed an assessment of size to guide treatment. CONCLUSION: Routine CXR after permanent pacemaker insertion is not necessary in uncomplicated cases with adequate pacing characteristics.
Right pneumothorax complicated by an endocardial atrial lead has never been reported. Herein, we report on a small-build 79-year-old Taiwanese woman who suffered from complete AV block and underwent dual-chamber permanent pacemaker implantation. An active fixation screw-in atrial lead was chosen. The procedure was complicated by right pneumothorax associated with atrial perforation. Since simple measurements of the implantation parameters could not be used to predict the occurrence of perforation, great caution should be taken in to avoid overscrewing the atrial lead, and in scrutinizing the penetration depth of the helix of the lead under fluoroscopy.
This study was performed to compare the frequency of early complications after single chamber versus dual chamber permanent pacemaker implantation. Early complication was defined as one occurring in the 6-week period following implantation. We prospectively analyzed consecutive pacemaker implantation from January 1987 to June 1993 at our regional center. All complications were also analyzed for the relationship to operator experience, the venous access route, and the presence of temporary pacing wire at the time of implantation of the permanent pacing system. A total of 2019 new pacemaker units were implanted during this period. 1733 patients (85.8%) received a VVI pacemaker and 286 (14.2%) a DDD unit. Wound infection occurred in 11 (0.6%) VVI patients and 6 (2.1%) DDD patients. Lead displacement occurred in 18 (1%) VVI patients and 15 (5.2%) DDD patients (11 [3.8%] atrial and 4 [1.4%] ventricular). There were 10 (0.6%) pneumothoraces, 9 (0.5%) hematomas requiring drainage, 1 (0.06%) chylocele, and 2 (0.1%) deaths in the VVI group. There were 2 (0.7%) pneumothoraces, 2 (0.7%) hematomas, and no deaths in the DDD group. There was no significant increase in complications for experienced infrequent implanters (< 12 systems per year). In both groups the subclavian approach was associated with a risk of pneumothorax when compared to the cephalic approach. The rate of wound infection was higher in patients who had a temporary pacing wire in place. The use of prophylactic antibiotics does not appear to affect the incidence of wound infection.(ABSTRACT TRUNCATED AT 250 WORDS)
The experience on 101 cases of permanent cardiac stimulation is reported; in all of them, the access was via the subclavian vein. Punction of the subclavian artery, transient injury of the brachial plexus and pneumothorax, were seen in 4.3 and 3% respectively. Early electrode luxation was observed in 5% of the patients. As late complications there where two cases of destruction of the electrode protecting sheet and one electrode rupture. In spite of the potential risks directly related to the vein puncture, the subclavian puncture offers an excellent alternative for placing definitive pacing electrodes.
The presence of pneumoperitoneum during laparoscopic antireflux surgery can lead to the dissection of carbon dioxide into the mediastinum, retroperitoneum, subcutaneous tissues, and neck (pneumodissection). The purpose of this study is to describe the incidence, extent, duration and pathways of pneumodissection during laparoscopic antireflux surgery. Twenty patients who underwent laparoscopic antireflux surgery from August 1998 through May 1999 were studied. Physical examination and chest radiographs were performed in the recovery room and each day postoperatively. Noncontrast computerized tomography (CT) of the neck, chest, and upper abdomen was also performed on postoperative day one. Subcutaneous emphysema and radiologic evidence of pneumodissection occurred commonly and typically resolved within 4 days postoperatively. The incidence of pneumomediastinum (85%) seen on CT scan was similar to that of pneumodissection into the neck (80%). The most common pathway of dissection of gas was through the anterior mediastinum and into the neck through the carotid space. Other findings on CT scan revealed pneumoperitoneum in 70 per cent, pneumoretroperitoneum in 10 per cent, and pneumothorax in 0 per cent. The dissection of gas into the mediastinum, neck, and subcutaneous tissues is very common after laparoscopic antireflux surgery. Subcutaneous emphysema on physical examination and radiographic pneumodissection typically resolves within 3 to 4 days. After this time one should consider the presence of any substantial amount of gas as a potential complication related to the procedure.
Abdominal distention during pneumoperitoneum results in a marked increase in plasma arginine vasopressin levels, which has been ascribed to an increase in intrathoracic pressure. Because of this relationship, tense ascites could contribute to nonosmotic release of antidiuretic hormone, to the development of hyponatremia, and eventually to further ascites formation. The effect of pneumoperitoneum, thoracocentesis, and paracentesis on plasma arginine vasopressin levels was studied in three groups of patients, and the mechanism by which these maneuvers may induce these changes was investigated. Patients with pleural effusion, pneumothorax, or ascites showed a significant increase in plasma arginine vasopressin levels, and thoracocentesis or paracentesis resulted in a decrease in these levels. Plasma vasopressin levels increased significantly during pneumoperitoneum, as did intrathoracic and atrial pressures; the atrial transmural pressure gradient declined. However, no changes in plasma levels of norepinephrine, aldosterone, and renin activity were observed during pneumoperitoneum. Changes in plasma arginine vasopressin levels correlated with the changes in intrathoracic and atrial pressures and transmural pressure gradient. The authors conclude that increased intrathoracic pressure is associated with an increase in plasma arginine vasopressin levels and propose that ascites could be a factor promoting vasopressin release by acting on intrathoracic volume receptors in decompensated cirrhotics.
BACKGROUND: Removal of the right middle and lower lobes often leaves a pleural space problem that can cause prolonged air leaks. METHODS: A single surgeon prospectively randomized 16 patients who underwent bilobectomy. Eight patients had 1200 mL of air injected under the right hemidiaphragm after bilobectomy and 8 did not. The air was injected through a small transdiaphragmatic opening made in the right hemidiaphragm at the time of pulmonary resection. RESULTS: The age of the patients, preoperative pulmonary function, preoperative comorbidities, indications for surgery, and final pathology were not significantly different between the two groups. On postoperative day #1, a pneumothorax was present in 1 patient (13%) in the pneumoperitoneum group (P group) and in 4 patients (50%) in the nonpneumoperitoneum group (N-P group). On postoperative day 1, an air leak was present in 1 patient (13%) in the P group and 5 patients (63%) in the N-P group (p < 0.001). By the third postoperative day, no patient in the P group had an air leak; however, a leak was present in 4 patients (50%) in the N-P group (p < 0.001). Median hospital stay in the P group was 4 days (range, 3 to 6 days), compared with 6 days (range, 4 to 8 days) in the N-P group (p < 0.001). Three patients in the N-P group were sent home with a Heimlich valve. There was no operative mortality and no complications from the pneumoperitoneum. CONCLUSIONS: We conclude that pneumoperitoneum after bilobectomy is safe and easy to do. It decreases the incidence of air leaks and of pneumothoraces and shortens hospital stay without increasing morbidity. We recommend pneumoperitoneum after bilobectomy at the time of thoracotomy, especially if there are residual small air leaks that cannot be sealed before chest closure.
PURPOSE: Side stream spirometry with dynamic compliance displayed as pressure-volume loops, has enabled early detection of CO2 pneumothorax during pneumoperitoneum. We compared dynamic compliance profiles of two laparoscopic procedures with different patient positions. METHODS: In 26 patients, scheduled either for laparoscopic fundoplication in a head-up tilt or inguinal herniorrhaphy in a head-down tilt, dynamic compliance was measured with continuous spirometry from anaesthesia induction until skin closure. Control pressure-volume loops were saved in the horizontal position before surgery and compared with succeeding loops in the head-up/head-down tilt before pneumoperitoneum, during pneumoperitoneum in the horizontal and the tilt position, after evacuation of pneumoperitoneum in the tilt and finally in the horizontal position. RESULTS: Pneumoperitoneum reduced compliance in both groups by 35% (P < 0.01). Head-down tilt decreased compliance by 12% before and during pneumoperitoneum (P < 0.01). Head-up tilt increased compliance by 4% before pneumoperitoneum (P < 0.05), but during pneumoperitoneum it had no effect. After evacuation of pneumoperitoneum compliance returned immediately to control in head-up tilt, but remained reduced in head-down tilt and was not at control after adopting horizontal position (P < 0.05). Difference between the groups was significant (P < 0.01) in the head-up/head-down tilt before, during and immediately after pneumoperitoneum. CONCLUSION: Both pneumoperitoneum and head-up and head-down positions had characteristic effects on dynamic compliance. Simultaneous display of sequential pressure-volume loops enabled immediate detection of changes in respiratory mechanics.
OBJECTIVE: To evaluate the incidence of intraoperative and early postoperative complications (up to two months after implant) of endocardial permanent pacemaker insertion in all patients under-going a first implant at a referral centre. METHODS: Prospective evaluation of all endocardial pacemaker implantation procedures performed from April 1992 to January 1994 carried out by completion of standard audit form at implant. Patients' demographic data, medical history, details of pacemaker hardware used, and any complications were noted. Follow up information was also collected prospectively onto standard forms at pacemaker outpatient clinic. SETTING: United Kingdom tertiary referral cardiothoracic centre. PATIENTS: 1088 consecutive patients underwent implantation of their first endocardial permanent pacemaker from April 1992 to January 1994. Implant and follow up data were available for 1059 (97.3%) patients at analysis. The median (range) age was 77 years (16-99); 51.2 % were male. RESULTS: Dual chamber units were implanted in 54.1% of patients, single chamber atrial in 5.2%, and ventricular in 40.7%. A temporary pacing lead was present at implant in 22.9% of patients. Most (93.6%) implants were performed via the subclavian vein. Immediate complications were rare: eight (0.8%) patients developed pneumothorax requiring medical treatment and 11 (1.0%) an insignificant pneumothorax. There was no significant difference in the pneumothorax rate for dual chamber (DDD) compared with single chamber systems. Arterial puncture without sequelae was documented in 2.7% of attempts at subclavian vein cannulation. A total of 35 patients (3.3%) required reoperation; the reoperation rate for dual chamber (3.5%) was similar to that for single chamber (3.1%) systems. Electrode displacement (n = 15, 1.4%) was the most common reason for reoperation. Atrial lead displacement (n = 10, 1.6% of atrial leads) was significantly more common than ventricular lead displacement (n = 5, 0.5% of ventricular leads, P = 0.047). There was no difference in electrode displacement rates for dual (1.6%) compared with single (1.2%) chamber systems. Pacemaker pocket infection led to reoperation in 10 patients (six dual, four single chamber, P = not significant) and was significantly more common in patients who had a temporary pacing lead in place at implant (2.9%) than in those who did not (0.4%, P = 0.0014). Five patients (0.5%) required reoperation for generator erosion (two dual, three single chamber, P = not significant). and a further five for drainage of haematoma or a serous fluid collection (three dual, two single chamber, P = not significant). Complications that did not require reoperation were also rare. Undersensing occurred in 10 patients (0.9%). Atrial undersensing (n = 8) was significantly more common than ventricular undersensing (n = 2, P = 0.017). All patients were successfully treated by reprogramming of sensitivity. Superficial wound infection was treated successfully with antibiotics in nine patients (six dual, three single chamber, P = not significant). Three patients with DDD generators developed sustained atrial fibrillation: two required reprogramming to VVI mode and one required cardioversion. CONCLUSIONS: Permanent pacing in a large tertiary referral centre with experienced operators carries a low risk. Infection rates are low, < 1% overall but significantly higher in patients who undergo temporary pacing before implantation. Lead displacement and undersensing are more likely to occur with atrial than ventricular leads. The overall complication rate for dual chamber pacing, however, is no higher than for single chamber pacing.
An endoscopic technique is described for thoracic sympathectomy. After establishment of a pneumothorax, the thoracoscope is introduced into the pleural cavity. The telescope is equipped with a wire electrode, a grasping forceps, and a suction coagulation probe for endoscopic electroresection of the sympathetic trunk. In 63 patients, 124 endoscopic sympathectomies were performed. All patients were relieved of sweating in the hands; 18.6% still had some perspiration of the axilla. Side effects of thoracic sympathectomy were compensatory and gustatory sweating that, in four patients, were more embarrassing than the original form of hyperhidrosis. Fifty-five patients were highly satisfied with the result of endoscopic sympathectomy, which is considered the appropriate minor procedure for the treatment of upper limb hyperhidrosis, causing minimal discomfort to the patient and almost invisible scars.
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Old scars of the pleura, for example from chronic empyema or therapeutic pneumothorax, can cause a malignant mesothelioma appearing some decades later. The authors describe two cases of primary pleural tumors, which probably had such an etiology. A literature review revealed 20 further cases, the majority of which were squamous cell carcinomas. Whether these tumors developed from metaplastic mesothelium or inplanted cells from the skin is not clear.
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In 148 cases the right internal jugular vein was used as the initial approach for percutaneous insertion of temporary endocardial pacemaker electrodes. Complications were few and none were serious. The technique of percutaneous cannulation of this vein for temporary endocardial pacing is described in detail.
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During the period 1947-1955, 148 patients underwent extrapleural pneumolysis for pulmonary tuberculosis in Stockholm City Chest Hospital at Söderby. In 121 tuberculosis healed following operation. Ten of these later developed pain and a feeling of tension on the operated side and were operated upon with evacuation of the extrapleural sac. In four of them a highly differentiated keratinizing aquamous cell carcinoma had developed. In addition, two more cases of carinomas of the same type operated on at other hospitals are described. Five of the six patients died of cancer. Squamous cell carcinoma occurring in metaplastic mesothelial cells has hitherto not been reported on and the phenomenon is discussed and compared with the more common scar cancers within lung tissue caused by damage from tuberculosis.