Descending necrotizing mediastinitis is a severe infection spreading from the cervical region to the mediastinum. Since this pathology is uncom mon, only a few reports of large series of patients with descending nec rotizing mediastinitis have been published. The present aim was to eval uate our treat ment strategy and survival for this disease by a retrospective chart review. Methods. Retrospective analysis of 45 cases with descending necrotizing mediastinitis was performed between 2002 and 2011. The mean age was 55.3 ± 15.4 years. The primary oropharyngeal infection was found in 16 (35.6%), an odontogenic abscess in 17 (37.7%) and other causes in 12 (26.7%) patients. Endo type I mediastinitis was assessed in 25 (56%) patients, Endo type IIA in 10 (22%) and Endo type IIB in 10 (22%) patients. Broad spectrum antibiotics were administered empirically and surgical treatment consisting of cervical drainage, thoracotomy with radical surgical debridement of the mediastinum and placement of permanent mediastinal irrigation were performed in all the cases. Results. Collar incision and drainage only were performed in 16 (35.6%) patients, whereas only transthoracic approach was used in five cases (11%). In the remaining 24 (53.4%) patients cervical drainage and thoracic operation were performed. Fifteen patients had severe complications: septic shock, multiple organ failure and haemorrhage from mediastinal vessels. The median hospital stay was 21 days. The outcome was favourable in 35 patients. Ten patients died (overall mortality 22.2%). There was a negative correlation between the time from the onset of symptoms till the first admittance to hospital and hospitalization time (Pearson correlation coefficient 0.357, p = 0.016). That allows us to suggest that time of illness spent at home without appropriate treatment plays a crucial role on the survival. It was found that younger age, Endo type I, negative bacterial culture and longer hospital stay are true precursors of favourable outcome. Conclusions. For descending necrotizing mediastinitis limited to the upper part of the mediastinum a transcervical approach and drainage may be sufficient. However, in advanced cases an immediate and more aggressive surgical approach is required to combat a much higher morbidity and mortality in this subset of patients.
1 StreszczenieWstęp: Rany kłute serca są dramatycznymi, prowadzącymi do zgonu urazami. Na ogół zdarzają się u ludzi młodych. Więk-szość ofiar umiera przed przyjęciem do szpitala. Cel pracy: Celem pracy było określenie czynników decydują-cych o wynikach leczenia i rokowaniu chorych z ranami kłu-tymi serca. , p = 0,031), wyższy stopień urazu (IV-VI) (90,5% vs 29,7%, p < 0,001), uraz prawego przedsionka (28,6% vs 8,5%, p = 0,014) lub lewej komory (42,9% vs 23,0%, p = 0,049) i epizody zatrzymania krążenia (85,7% vs 7,9%, p < 0,001). Niezależnym prognostycznym czynnikiem przeżycia była obecność wszystkich czynników SOL oraz młodszy wiek. Wyższy stopień urazu (IV-VI) oraz zatrzymanie krążenia w trakcie operacji były niezależnymi czynnikami zgonu. Wnioski: Prekursorami złego rokowania były niższe wartości ciśnienia tętniczego oraz brak co najmniej jednego z czynni- CARDIAC SURGERY AbstractBackground: Penetrating cardiac injuries are a dramatic and lethal form of trauma. They are usually sustained by young people. The majority of victims die before reaching the hospital. Aim of the study: The aim of the study was to establish prognostic criteria for the outcome of penetrating cardiac injury. Material and methods: We retrospectively reviewed the records of 186 patients with penetrating cardiac injuries who were operated on during the first 24 hours after admission. Results: The mean age was 33 (interquartile range (IQR): 26-44) years. 88.7% of victims were male. The mean time from the moment of trauma to arrival at the hospital in Vilnius city was 60 minutes (IQR: 50-91), whereas from the Vilnius region it was 240 (IQR: 82-390) minutes. The vast majority of patients (176/186, 94.6%) sustained stab wounds. Hemopericardium or cardiac tamponade (142/186, 76.3%) usually was found at the operation. Right ventricle was the most often injured heart chamber (75/186, 40.3%). Associated injuries were evaluated in 57.0% (106/186) of patients. The survival rate on discharge was 88.7%. Compared to non-survivors, the lucky patients had a higher systolic blood pressure on admission (94 mm Hg (IQR: 70-120) versus (vs.) 70 mm Hg (IQR: 0-80), p < 0.001). Survivors had all signs of life (SOL) more often (82.4% vs. 42.9%, p < 0.001), whereas more frequent findings in non-survivors were the following: tamponade (52.4% vs. 29.1%, p = 0.031), higher grade (IV-VI) of injury (90.5% vs. 29.7%, p < 0.001), injured right atrium (28.6% vs. 8.5% p = 0.014) or left ventricle (42.9% vs. 23.0%, p = 0.049) and an episode of heart arrest (85.7% vs. 7.9%, p < 0.001). Independent prognostic factors of survival were the presence of all SOL and younger age. Higher grade (IV-VI) of heart injury and heart arrest during surgery independently predicted mortality. Conclusions: According to our data, lower arterial blood pressure and absence of one or more SOL on admission, cardiac tamponade, higher grade injury, injured right atrium and asystole during operation are true precursors of fatal outcome.
BackgroundLipomas are distinctly uncommon benign tumours of the esophagus. Lipoma and other benign tumours should be consid ered for patients admitted to the hospital with nonspecific complaints of upper gastrointestinal tract disease. Radiological and endoscopic suspicion of a tumour with benign histology and correct preoperative histological diagnosis are important factors in order to choose the best surgical treatment option. Case report A 59yearold woman was admitted with dysphagia lasting for about 1.5 months. Endoscopy and computed tomography scan revealed intraluminal pedunculated submucosal mass, 13 cm in length and 2 cm in diameter, -67 Hounsfield units in density, suggesting esophageal lipoma to be the most likely diagnosis. Tumour was excised through right lateral thoracotomy with esophagotomy. Barium esophagogram in the postoperative period showed esophageal leakage, hence rethoracotomy was performed and the defect was attempted to close by sutures. Repeated barium esophagogram revealed persisting evidences of esophageal leakage so biodegradable coated 10 cm in length and 31/25/31 mm in diameter SXELLA stent was used and successfully sealed the leakage. Conclusion Giant esophageal lipoma is a rare benign esophageal tumour causing dysphagia. Open surgery is the best treatment option for giant esophageal lipomas. However, postoperative complications such as esophageal leakage are common in patients after open esophageal surgery. Biodegradable stent could be successfully used dealing with persistent esophageal leakage. Key words: dysphagia, esophageal lipoma, esophagotomy, mediastinitis, esophagopleural fistula. J . K a t i n a i t ė , Ž . J a g e l a v i č i u s , A . K y b a r t a s , V . G r u s l y s , R . J a n i l i o n i s ĮžangaLipoma -retas nepiktybinis stemplės navikas. Tiriant pacientus dėl nespecifinių viršutinio virškinamojo trakto ligos simptomų, reikėtų nepamiršti nepiktybinių stemplės navikų. Vaizdiniais tyrimais įtartas nepiktybinis stemplės navikas ir tiksliai nustatyta histologinė diagnozė priešoperaciniu laikotarpiu yra svarbūs veiksniai pasirenkant tinkamiausią gydymo metodą bei siekiant išvengti sudėtingesnių chirurginių procedūrų. Klinikinis atvejisMoteris, 59 metų amžiaus, buvo paguldyta į chirurgijos skyrių dėl disfagijos, trunkančios apie 1,5 mėnesio. Endoskopiškai įtartas stemplės pogleivio navikas. Atlikus krūtinės ląstos kompiuterinės tomografijos tyrimą rastas 13 cm ilgio ir 2 cm pločio, -67 Houn sfieldo vienetų tankio intraluminalinis pogleivio darinys ant kojytės. Radiologiškai labiausiai tikėtina diagnozė buvo stemplės li poma. Navikas pašalintas atlikus ezofagotomiją per dešinės pusės torakotominį pjūvį. Pooperaciniu laikotarpiu atlikta kontrastinė ezofagograma parodė stemplės nesandarumo požymius. Buvo atlikta retorakotomija ir stemplės defektas užsiūtas. Kartotinis ra diologinis stemplės tyrimas parodė, kad stemplės nesandarumas išliko. Tuomet į stemplę buvo implantuotas biodegraduojantis SXELLA dengtas 10 cm ilgio, 31/25/31 mm išorinio skersmens stentas, kuriuo defek...
Įvadas / tikslasPleuros empiema – viena iš seniausiai žinomų krūtinės ligų ir iki šiol yra susijusi su didėjančiu sergamumu visame pasaulyje. Kaip ir daugelyje chirurgijos sričių, gydant pūlinėmis pleuros ligomis sergančius ligonius populiarėja minimaliai invazinės chirurginės procedūros. Tačiau torakoskopinė operacija vis dar negali pakeisti atvirosios visais empiemų atvejais. Šiame straipsnyje supažindiname su mūsų atliekamų torakoskopinių pleuros empiemos operacijų metodika ir aptariame pradinę patirtį.Ligoniai ir metodaiNuo 2011 m. sausio iki 2013 m. rugsėjo torakoskopiškai buvo operuoti 49 ligoniai, sergantys pleuros empiema. Visi pacientai operuoti sukėlus bendrinę nejautrą, naudojant vieno plaučio ventiliaciją. Visos torakoskopinės operacijos buvo padarytos per dvi arba tris angas krūtinėje. Tais atvejais, kai sėkmingai atlikti torakoskopiniu būdu empiemektomijos nepavykdavo, būdavo pereinama į atvirąją (torakotominę) operaciją.RezultataiSėkmingai videotorakoskopinė operacija buvo atlikta 36 (73,5 %) ligoniams, o 13 (26,5 %) atvejų prireikė konversijos į atvirą operaciją. Pleuros ertmės sąaugos ir negalėjimas iki galo pašalinti ant plaučio paviršiaus susidariusio jį kaustančio šarvo buvo pagrindinės konversijų priežastys. Dešimt (20 %) ligonių patyrė tokių pooperacinių komplikacijų kaip ligos atkrytis, ilgesnį laiką besiskiriantis pro drenus oras, žaizdos infekcija.IšvadosPleuros empiemos atveju minimaliai invazinė chirurgija yra saugi ir pakankamai efektyvi. Tačiau turėtume ieškoti tam tikrų veiksnių, kurie padėtų atrinkti asmenis, tinkamus sėkmingai torakoskopinei pleuros empiemos operacijai.Reikšminiai žodžiai: pleuros empiema, piotoraksas, videoasistuojamoji krūtinės chirurgija, empiemektomija, dekortikacija Successful video-assisted thoracic surgery for pleural empyemaŽymantas Jagelavičius, Vytautas Jovaišas, Algis Kybartas, Arūnas Žilinskas, Lina Lukoševičiūtė, Ričardas Janilionis, Narimantas Evaldas Samalavičius Background / ObjectiveFew thoracic conditions present such a considerable challenge as does pleural empyema. The disease is known since Hippocrates’ time, nonetheless it is still associated with the rising incidence all over the world. Minimally invasive procedures become more and more popular in many fields of surgery as well as in patients with pleural empyema. However, video-assisted thoracoscopy cannot replace open surgery in all empyema cases. In this report, we would like to present our thoracoscopic technique and preliminary experience in treating patients with pleural empyema.Patients and methodsDuring the period from January 2011 till September 2013, thoracoscopic empyemectomy was performed in 49 patients. All patients were operated on under general anaesthesia using single lung ventilation. All procedures were performed through two or three ports. Conversion to thoracotomy was performed when it was impossible to make successfully thoracoscopic empyemectomy.ResultsA video-assisted thoracoscopic operation was successful in 36 (73.5%) patients, whereas in 13 (26.5 %) cases a conversion was required. Pleural space adhesions and inability to remove completely the peel from the underlying lung were the main reasons for conversion. Ten (20%) patients had postoperative complications such as recurrence of disease, prolonged air leak, or wound infection.ConclusionsMinimally invasive surgery is a safe and effective treating of patients with pleural empyema. However, we should search for preoperative factors of identifying the right persons who could be cured successfully by video-assisted thoracoscopic surgery.Key words: pleural empyema, pyothorax, video-assisted thoracic surgery, empyemectomy, debridement, decortication
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