Chest wall deformities and thoracic scoliosis after costal cartilage graft harvesting

Donor-site complications, specifically chest wall deformities and thoracic scoliosis, occurring after harvest of costal cartilage grafts are presented and discussed. The cases of 18 patients (12 male and 6 female), who underwent costal cartilage grafts for microtia reconstruction from 1975 to 1993, were reviewed for donor-site complications using radiography and physical examination. Ribs from which costal cartilage had been harvested showed increased inward bowing on radiographs in 16 of 32 donor sites. The frequency of rib deformity in donor sites was 20.0 percent when cartilages were harvested from patients older than 10 years of age, whereas it was 63.6 percent in patients younger than 10 years old. This difference was statistically significant (p = 0.027, Fisher's exact test), although only 32 grafts were performed in 18 cases. The upper ribs demonstrate a higher incidence of deformity than lower ribs. Thoracic scoliosis was found in 4 of 16 cases. The biomechanical impact of these deformities was considered because of respiratory movement of the thorax and injury to the germinal growth center of the ribs. We recommend delaying costal cartilage grafts for as long as possible, leaving the costochondral junction intact to minimize chest wall deformity and thoracic scoliosis.     

The analysis of sex segregation: when is index measurement not index measurement?

Starting in 1989, an attempt was made to change the aim of methadone treatment in NSW from abstinence to harm-minimisation. A study was undertaken to measure change in attitudes among staff working in public methadone programs in Sydney. Using scales developed in a 1989 survey, we found a statistically significant and meaningful reduction in support for abstinence-oriented policies had occurred by 1992. There was no change in staff's support for the punishment of illicit drug use or their knowledge of the risks and benefits of methadone maintenance. This suggests problems with staff attitudes and, indirectly, the effectiveness of public health interventions, can be addressed using educational campaigns.     

Errors in measurement of acetabular index

The usefulness of the fPSA fraction in the differential diagnosis of benign prostate hyperplasia (BPH) and prostate cancer was evaluated, with the aim of improving the diagnostic efficacy of PSA. Serum PSA and fPSA determinations were performed by an enzymoimmunoassay technique on an ES-300 system. fPSA constitutes a minor fraction both in normal subjects and in patients with prostate disease, being significantly lower in patients with untreated prostate cancer than in patients with BPH. Likewise, the authors have observed that the sensitivity of the fPSA/PSA ratio has an inversely proportional relationship with the stage of the disease. The results obtained in patients with PSA levels between 4 and 20 micrograms/l are also of note. In this series of patients, the efficacy of the fPSA/PSA ratio was higher than that of PSA, showing a sensitivity of 44% and a specificity of 95% at the cut-off of 0.08.     

The simplified version of Boyle's Law leads to errors in the measurement of thoracic gas volume

When using Boyle's Law for thoracic gas volume (Vtg) measurement, it is generally assumed that the alveolar pressure (Palv) does not differ from barometric pressure (Pbar) at the start of rarefaction and compression and that the product of the change in volume and pressure (delta P x delta V) is negligibly small. In a gentle panting maneuver in which the difference between Palv and Pbar is small, errors introduced by these assumptions are likely to be small; however, this is not the case when Vtg is measured using a single vigorous inspiratory effort. Discrepancies in the Vtg between the "complex" version of Boyle's Law, which does not ignore delta P x delta V and accounts for large swings in Palv, and the "simplified" version, during both a panting maneuver and a single inspiratory effort were calculated for normal control subjects and patients with cystic fibrosis or asthma. Defining the Vtg from the complete version as "correct," the errors introduced by the simplified version ranged from -3 to +3% for the panting maneuver whereas they ranged from 2 to 9% for the inspiratory maneuver. Using the simplified equation, the Vtg for the inspiratory maneuver was 0.135 +/- 0.237 L greater (p < 0.02) than for the panting maneuver. This discrepancy disappeared when the complete equation was used. While the errors introduced by the use of the simplified version of Boyle's Law are small, they are systematic and unnecessary.     

Clinical value of renovascular resistive index measurement in the diagnosis of acute obstructive uropathy

PURPOSE: We evaluated the clinical use of the renal resistive index in identifying patients with acute urinary tract obstruction. MATERIALS AND METHODS: Of 54 patients with suspected acute urinary tract obstruction who underwent measurements of renal resistive index 19 had unilateral obstruction documented with excretory urography and comprise our study sample. The contralateral nonobstructed kidneys served as controls. Criteria for obstruction were a resistive index of 0.70 or greater or a side to side difference of 0.10 or greater. We calculated sensitivity, specificity, and positive and negative predictive values. RESULTS: Sensitivity for obstruction was 42% with 11 false-positive cases, specificity was 79%, and positive and negative predictive values were 67 and 57%, respectively. CONCLUSIONS: Renal resistive index measurements are not valuable in detecting acute urinary tract obstruction.     

Hepatic Doppler perfusion index: measurement in nine healthy volunteers

Nine healthy volunteers were studied to validate the reproducibility of the Doppler perfusion index--the ratio of hepatic arterial to total liver blood flow--and to evaluate the method of its derivation and the influence of the variable parameters necessary for its calculation. Wide intraobserver variability was observed, and Doppler perfusion index values were consistently outside the previously reported normal range.     

Chest radiography in the ICU

Proper positioning and assessment of abnormalities and complications of the above-mentioned devices have a significant impact on the management of critically ill patients in the intensive care unit (ICU). The timely assessment of new or rapidly evolving findings is critical. Optimal radiographic technique, availability of images to the clinicians, and rapid reporting by the radiologist all serve to maximize the efficacy of bedside chest radiography in the ICU. Sometimes, changes in cardiopulmonary status may only be appreciated on chest radiographs (CXRs). Complications from ventilatory assistance, such as barotrauma, occur frequently and must be detected promptly. The position of monitoring devices, an important component of critical care management, is best checked radiographically. Indications for CXRs and the recommended frequency for repeat follow-up CXRs are based on the existing literature and the consensus of an expert panel formed by the American College of Radiology.     

Use of the thoracic aorta for renal revascularization

OBJECTIVE: The primary role of the anterior cruciate ligament is to resist anterior subluxation of the tibia. When the ligament is torn, the tibia is free to sublux anteriorly when the leg is pulled forward. In addition to visualizing the anterior cruciate ligament directly, MR imaging can show joint alignment. The purpose of this study was to test the efficacy of MR images of anterior subluxation of the tibia for diagnosing complete tears of the anterior cruciate ligament. MATERIALS AND METHODS: We evaluated the records of 120 consecutive patients who underwent MR imaging of the knee and subsequently had arthroscopy. Arthroscopy showed a complete tear of the anterior cruciate ligament in 21 patients, a partial tear in eight patients, and an intact anterior cruciate ligament in 91 patients. Two radiologists together reviewed the MR images, and interpretation of anterior cruciate ligament integrity was reached by consensus. The anterior cruciate ligament was categorized as intact, completely torn, or partially torn on the basis of conventional MR imaging criteria. The degree of anterior subluxation of the tibia was measured on a separate occasion in random order by a radiologist who used a sagittal section through the middle of the lateral femoral condyle. On the selected image, two vertical lines parallel to the left and right margins of the image frame were drawn tangent to the posterior cortical margins of the lateral femoral and tibial condyles. Anterior subluxation of the tibia was determined by the distance in millimeters between these two lines and measured with calipers by using the 5-cm scale on the images. Measurements were considered reliable only to one half of the smallest increment of this scale (i.e., 5 mm). Accordingly, tibial subluxation (x) was measured in 5-mm increments, with x < or = 0 mm designated grade 0, 0 mm < x < or = 5 mm designated grade 1, 5 mm < x < or = 10 mm designated grade 2, and so forth. RESULTS: Conventional MR imaging criteria had 90% sensitivity and 94% specificity for diagnosing complete tears of the anterior cruciate ligament. According to the receiver-operating-characteristic (ROC) curve, anterior subluxation of the tibia greater than 5 mm (grade 2 or greater) was considered to be the optimal threshold (sensitivity, 86%; specificity, 99%) for diagnosing complete tears of the anterior cruciate ligament. Notably, none of the six false-positive diagnoses of complete tears by conventional criteria (three partial tears and three intact ligaments at arthroscopy) were misdiagnosed when tibial subluxation was used as the diagnostic criterion. Subluxation greater than 5 mm can be falsely negative with chronic tears of the anterior cruciate ligament (n = 2) or when a displaced bucket-handle tear of the lateral meniscus blocks anterior subluxation of the tibia (n = 1). CONCLUSION: An anterior tibial subluxation greater than 5 mm (grade 2 or greater) is a simple objective measurement that serves as a helpful adjunctive sign in the diagnosis of complete tears of the anterior cruciate ligament. This sign also offers improved discrimination of complete from partial tears of the anterior cruciate ligament.     

Postoperative prognostic factors for carcinoma of the thoracic esophagus

To evaluate significant postoperative prognostic factors for esophageal carcinoma, clinicopathological findings and several markers for biological malignant potential were studied, including cell nuclear DNA contents, EGF receptor, p53 protein, MMP-2, Ki-67 positive cell rate, and tumors infiltrating Leu 7 cells. The subjects of this study were 96 patients with thoracic esophageal carcinoma, who underwent radical surgery with extended lymphadenectomy. In the pathological findings, the postoperative survival rate significantly correlated with depth of invasion (pT1(-2) vs. pT3, p = 0.003), lymph node involvement (pNo vs. pN1, p = 0.0002), vascular invasion (-vs. +, p = 0.0003), stage (pSt. 1-2A vs. 3, p = 0.0018), and the number of node involvements (1-3 vs. more than 4, p = 0.025). Analyzing the markers for the malignancy, a significant difference in postoperative mortality due to the relapse was recognized with p value of 0.0009 between Ki-67 positive (under 1%) and Ki-67 negative (over 1%) tumor. Ki-67 positive tumor significantly correlated with the mortality in both cases with pNo (p = 0.024) and pN1 (p = 0.020). Low-grade tumor infiltrating Leu 7 cells significantly correlated with the mortality (Grade 1+ vs. 2+, p = 0.013; Grade 1+ vs. 3+, p = 0.008). These results suggest that Ki-67 study is a useful prognostic factor after radical surgery for thoracic esophageal carcinoma.     

Chest pain in the presentation of sarcoidosis

The cases of six patients are reported illustrating that chest pain may be a prominent feature of sarcoidosis. It may be severe and be the chief presenting symptom. In the cases described it was mostly retrosternal and had few consistent aggravating factors. In each case there was bilateral hilar lymph node enlargement and it is suggested that htis was chiefly responsible for this relatively uncommon symptom of sarcoidosis. It is also suggested that undue persisting pain may respond to corticosteroid administration.     

Damage control for thoracic injuries

Some of the earliest damage control techniques were applied to the chest during emergency center thoracotomy. It provided a paradigm that was adapted to other areas. Damage control of chest injuries has a different philosophy than that of abdominal injuries. Damage control in the abdomen primarily consists of multiple staged operations with abbreviated closures. Damage control in the chest consists of different technical maneuvers to use quicker and technically less demanding operations to accomplish the same goal. The philosophy of doing only enough to restore a survivable physiology is still a common theme. The following are the major principles of damage control for thoracic injuries: 1. Emergency center thoracotomy is a damage control prototype. 2. Anterolateral thoracotomy is the empiric incision of choice in the patient in extremis. 3. Nonanatomically stapled lung resections, pulmonary tractotomy, and en masse lobectomy/pneumonectomy are pulmonary damage control procedures. 4. The unique physiology of the chest may require en masse closure of muscles or patch closure of the wound. 5. Cardiopulmonary physiology can be affected by packing. Packing thus has a limited role in thoracic damage control. 6. Prosthetic grafts, intravascular shunts, and ligation are common thoracic vascular damage control techniques. 7. With new technology, an increased role for cardiopulmonary bypass and cardiac assistance may develop. 8. New technology must not overly complicate a procedure if it is to be a valuable damage control adjunct.     

Video-assisted thoracic surgery for diagnosis of the solitary lung nodule

The finding of a solitary pulmonary nodule is a frequent clinical problem. This article outlines the current recommendation for diagnostic management. Video-assisted thoracic surgery (VATS) has emerged as an excellent diagnostic tool that can reduce the incidence of thoracotomy for benign nodules while allowing expeditious treatment of early malignancies. The surgical techniques of VATS are discussed.     

Chest trauma: the role of transesophageal echocardiography

Aortic and cardiac injury is commonly seen with severe chest trauma and contributes to the morbidity and mortality of automobile accidents. Transesophageal echocardiography is emerging as an important diagnostic tool for the evaluation of cardiovascular injury in the setting of acute chest trauma, and anesthesiologists should be familiar with the echocardiographic features of these traumatic lesions.     

Chondrosarcoma of the thoracic wall

In this paper, three placebo-controlled trials of moclobemide, and four three-way comparison trials of moclobemide, placebo and one of the standard tricyclic antidepressants, imipramine, clomipramine, or amitriptyline, are reviewed. The results of the placebo-controlled trials indicate that about twice as many of the patients receiving moclobemide showed a marked improvement during a four-week treatment period, as compared with patients receiving placebo. Of the three-way trials, two studies indicated that the efficacy of moclobemide was significantly greater than that of placebo and similar to that of other antidepressants (imipramine or amitriptyline). Tolerance of moclobemide was good and better than that of the tricyclic antidepressants. In the other three-way comparison trials, the differences in efficacy between the placebo, moclobemide, and the tricyclic antidepressant were not significant.     

Myelolipoma of the thoracic spine

We describe a myelolipoma of the thoracic spine in a patient with gradual and progressive myelopathy. MR imaging showed this predominately fatty lesion to be extradural in location.     

Strategic planning for video-assisted thoracic surgery

As with any operative procedure, careful preoperative and intraoperative planning are vital to achieving a safe and effective video-assisted thoracic surgical intervention. We outline some of our basic strategies for enhancing the success of this approach in the management of thoracic surgical problems.     

Total thoracic esophagectomy for esophageal cancer

BACKGROUND: Many current methods of esophageal resection have drawbacks that result in inadequate proximal resection, inadequate lymphadenectomy, and difficult gastric and splenic access. We describe a technique that allows reliable and safe access to the chest, abdomen, and neck. STUDY DESIGN: From 1988 to 1995, 113 patients (82 men; mean age 65.3 +/- 4.5 years) with carcinoma of the esophagus or esophagogastric junction (middle third in 34, lower third in 41, and cardia in 38) underwent total thoracic esophagectomy. The histology was adenocarcinoma in 71 (62.8%), squamous cell carcinoma in 32 (28.3%), and undifferentiated carcinoma in 10 (8.9%) of the patients; 57 tumors (50.5%) were stage III. The esophagus and stomach were mobilized through a left thoracoabdominal incision. After completion of the esophageal resection, the fundus of the stomach was sutured to the esophageal stump to allow later delivery of the stomach into the neck. The esophagogastric anastomosis was performed with continuous single-layer absorbable suture through a left oblique cervical incision. RESULTS: The mean duration of the operation was 309.2 +/- 47.9 minutes. Hospital stay ranged from 5 to 49 days (median, 12 days). The perioperative mortality rate was 4.4%. Anastomotic leak occurred in six patients (5.3%), one of whom died. The proximal resection margin was microscopically free of tumor in all cases, and with a minimum followup period of 18 months, there has been no anastomotic recurrence in any patient. Actuarial survival at 1 year was 63.4% +/- 4.9%, at 3 years 41.4% +/- 5.9%, and at 5 years 22.7% +/- 6.3%. CONCLUSIONS: Total thoracic esophagectomy through the left chest with a separate left cervical incision allows clear access to the esophagus and stomach and good tumor clearance. This procedure may be performed with a low rate of anastomotic leakage, a very low mortality rate, and no anastomotic tumor recurrence.