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Blunt traumatic rupture of the diaphragm must be suspected in all patients with massive trauma and especially in those whose chest roentgenogram reveals an abnormal or obscured diaphragmatic shadow. Regular reevaluation is most important. A diagnostic pneumoperitoneum is the most accurate preoperative test available. Transthoracic approach is the operation of choice.
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BACKGROUND: The hemodynamic effects of carbon dioxide insufflation under single-lung ventilation were studied in 22 consecutive thoracoscopic harvests of the left internal mammary artery, which was used for minimally invasive coronary artery bypass grafting. METHODS: An electrocardiograph, arterial catheter, Swan-Ganz catheter, and transesophageal echocardiograph were used to monitor seven hemodynamic variables. Baseline data were obtained during ventilation of both lungs and the measurements were repeated after the left lung was collapsed and at 5 and 30 minutes after hemithorax insufflation with low-flow (2 to 3 L/minute) carbon dioxide gas was begun. The intrapleural pressure was maintained at 8 to 10 mm Hg. RESULTS: Thoracoscopic harvest of the internal mammary artery was completed in all cases with a mean insufflation time of 44+/-12 minutes. There were no significant changes in the mean arterial pressure, heart rate, cardiac index, and left ventricular ejection fraction throughout the procedure, whereas the central venous pressure, mean pulmonary arterial pressure, and pulmonary capillary wedge pressure (p < 0.05 for each variable) during insufflation. CONCLUSIONS: Low-flow carbon dioxide insufflation into the left hemithorax with an intrapleural pressure of 8 to 10 mm Hg under selective right-lung ventilation does not compromise the human heart with normal to moderately depressed function and can be an efficacious adjunct in specific thoracoscopic procedures.
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INTRODUCTION: Adult pulmonary Langerhans'cell histiocytosis, also referred to as histiocytosis X, is a disorder of unknown etiology which affects preferentially young smokers. The disease is characterized by granulomatous lesions which progressively invade and destroy distal airways, leading to the formation of characteristic cicatricial kystic lesions. Florid granulomas contain numerous Langerhans'cells, antigen-presenting cells of the dendritic cell lineage, associated with T lymphocytes and eosinophils. The diagnosis rests on the combination of clinical and radiologic data, and particularly on high-resolution CT scan findings showing a typical association of nodular and cystic changes, predominantly in the upper and middle lobes. Further evaluation with surgical lung biopsy is indicated in less typical situations. CURRENT KNOWLEDGE AND KEY POINTS: The pathogenesis of Langerhans'cell histiocytosis is not fully understood, but several arguments suggest that the disease results from an abnormal immune reaction initiated by Langerhans'cells and directed against the bronchial epithelium. Other arguments suggest the presence of genetic abnormalities susceptible, for example, to increase the sensitivity of these cells to cytokines (GM-CSF, or others) known to influence their survival and maturation. FUTURE PROSPECTS AND PROJECTS: These recent advances in the pathogenesis of Langerhans'cell histiocytosis could promote the development of new therapeutic strategies designed to regulate the number and activated state of Langerhans'cells in specific lesions.
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Squamous-cell carcinoma into an extrapleural pneumothorax for active tuberculosis was incorrectly diagnosed as late tubercular empyema. Right axillary thoracostomy was carried out to drain large dense effusion decompressing the brachial plexus and the sympathetic chain with symptomatic release. Surgical biopsy of the extrapleural sac allowed to identify two different tissues: normal epithelium similar to epidermis and nodular fragments composed of well-differentiated squamous carcinoma. The cause of this tumour is not clear: probably the carcinoma arose from normal epidermis carried in the extrapleural cavity during multiple air-refills to maintain the therapeutic pneumothorax.
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As the equipment and technique have improved, minimally invasive surgery is being applied to younger and younger children. With the advent of this valuable surgical technique, there are also specific modifications necessary in the anaesthetic technique. When considering the anaesthetic implications of these patients, one must account for both the patient's underlying status as well as physiological derangements induced by the surgical procedure. The following article attempts to address and review the specific anaesthetic implications of thoracoscopic procedures in neonates, infants, and children including the preoperative evaluation, intraoperative care and monitoring, and postoperative issues including analgesia. The techniques of one-lung anaesthesia, commonly required for thoracoscopy, are reviewed as well as consideration of the adverse effects which can occur during thoracoscopy including inadvertent intravascular CO2 embolism.
The surgical requirement for thoracoscopy is a good view of the contents of the thorax. This is achieved by capitalizing on natural consequences and the skills of anaesthesiologists to produce a pneumothorax and collapse the ipsilateral lung--a process that is commonly enhanced by insufflating carbon dioxide. Insufflating CO2 to actively promote lung collapse creates the dynamics of a tension pneumothorax. Complications are clinically insignificant if CO2 is used judiciously. There is a body of experience using ordinary endotracheal tubes and two-lung ventilation. Techniques of one-lung ventilation are more widely reported. All the factors known to contribute to the significant increase in shunt fraction associated with one-lung ventilation apply. The manoeuvre of collapsing a lung is no longer regarded as benign. Chemical attempts to produce a reversible post-pneumonectomy pulmonary circulation have not been shown to be an improvement. Post-operative pain can be severe. The mechanism is not defined but it differs from that associated with thoracotomy. Epidural analgesia and opioids may be required. Chronic pain syndromes have been described as complications.
PURPOSE: The aim of this report is to assess the technique and outcome of thoracoscopic lobectomy for asymptomatic prenatally diagnosed lung lesions. METHODS: From June 1999 to March 2002, 14 consecutive asymptomatic patients with a prenatal diagnosis of congenital cystic adenomatoid malformation or pulmonary sequestration, ages 3 to 15 months, underwent postnatal thoracoscopic lobectomy. Single-lung ventilation and controlled pneumothorax with low pressure (4 torr) and low flow (1.0 L/min) were used in all. Follow-up ranged from 4 to 35 months. RESULTS: All procedures were completed successfully using 3 ports. Rather than using stapling devices or clips, pulmonary vessels were sealed and the fissure completed (when necessary) with the Ligasure thermal energy device. Eleven lesions were on the left (10 lower lobe), and 3 were in the right lower lobe. The mean operating time was 110 minutes. The average hospital stay was 38 hours. There were no intraoperative or postoperative complications. CONCLUSIONS: This is the first report of a completely thoracoscopic technique for pulmonary lobectomy in small children. Thoracoscopic lobectomy is a relatively quick and safe procedure, and the cosmetic result is excellent. Early resection obviates the risk of infection in these lesions.