Thoracoscopic treatment of mediastinal cysts in children

BACKGROUND/PURPOSE: The development of thoracoscopic surgery has made many procedures possible, including the treatment of mediastinal cysts in children. The authors report their experience with this procedure between 1992 and 1997. METHODS: Surgery was performed on 22 children aged from 1 month to 9 years (median, 27 months), weighing 5 to 49 kg (median, 12.5 kg). Diagnosis was made by antenatal ultrasound scan in six cases (27%), with a chest x-ray performed for respiratory symptoms in 14 cases, and with a chest x-ray performed for positive tuberculin intradermoreaction in two cases. Decision to resect the cyst was determined by thoracoscopy in 21 of the 22 cases, and by open surgery in one case only (subcarinal compressive cyst with left lung distension and a mediastinal shift). RESULTS: Eighteen of the 21 (86%) cases were treated successfully by thoracoscopy. In three cases of bronchogenic cysts, we performed an associated thoracotomy because the dissection was too difficult and dangerous. In three cases, a small part of a common wall between the cyst and the bronchus was not removed. The pathological diagnosis was bronchogenic cysts in 15 cases (71%), pleuropericardiat cysts in three cases (14%), esophageal duplication in two cases (10%), and cystic hygroma in one case (5%). Two postoperative complications were observed: one esophageal wound and a case of recurrent pneumothorax after chest tube removal. Patients were discharged after 2 to 11 days (median, 3 days). Follow-up was uneventful. CONCLUSIONS: Treatment of mediastinal cyst by thoracoscopy is feasible in most cases. Compressive cysts with lung distension and mediastinal shift remain a contraindication. If the cysts have a common wall with the bronchus or esophagus, or if they are subcarinal, the dissection may be difficult and dangerous, and thoracotomy may be preferable.     

Intraoperative spinal sonography in the cervical anterior approach

Intraoperative spinal sonography was used during cervical anterior approach procedures for cervical discectomy and osteophytectomy to demonstrate spinal pulsation, the protruded disc or osteophyte, the anterior subarachnoid space, and the spinal cord. Spinal pulsation was recognized in some cases before removal of the disc but the anterior subarachnoid space and spinal cord could not be observed. However, the latter were more clearly observed during removal of the disc and could be seen after total removal of the disc and osteophyte. This method allows confirmation of decompression and pulsation of the spinal cord without cutting and removal of the posterior longitudinal ligament.     

Secondary extradural spinal tumours in children

Secondary extradural spinal tumours are very rare, but they comprise most of the extradural neoplasms seen in infancy and childhood. Thirty-nine patients with this type of secondary tumour were treated in our hospital between 1965 and 1991. The diagnosis was proved by biopsy in every case. Following surgical decompression, all 35 survivors had radiotherapy and/or chemotherapy. Their outcome is reported.     

One-stage internal fixation and anterior fusion in complex cervical spinal disorders

The authors describe their experience with the Morscher titanium cervical plate with cancellous locking screws in the management of complex cervical spine disorders. Fifty patients (32 males and 18 females) with a mean age of 54 years (range 10 to 84 years) underwent anterior spinal fixation that extended two to five vertebral bodies, using a titanium cervical plate and autogenous bone graft. Surgeries were performed for a variety of reasons: one for a congenital lesion, five for spinal neoplasms, nine for trauma, and 35 for degenerative arthritides. Ten patients had symptomatic kyphoses due to previous laminectomy, failed anterior surgery, or trauma. Satisfactory fixation and fusion with no neurological deterioration was obtained in all but two cases. Specific complications included six cases of dysphagia, one of sepsis, one of Horner's syndrome, and one case in which the patient had a fatal myocardial infarction the night after surgery. At the end of the follow-up period, fusion was found to have occurred in all remaining cases with no outstanding implant-related problems.     

Thoracoscopic truncal vagotomy

Abdominal re-operation in patients with recurrent peptic ulcer disease is associated with a high morbidity rate and a mortality rate of 5%. As an alternative procedure, therefore, transthoracic truncal vagotomy was early recommended as a less invasive intervention, and good results can be achieved with it. With the development of minimal invasive surgery, this procedure can now be performed via thoracoscopy and patient stress thus reduced even further. Via a left-sided thoracoscopy, the parietal pleura is incised and a 3-5 cm long segment of the distal oesophagus mobilised and dissected free. Both the posterior and anterior trunks of the vagus nerves are identified and, after applying clips, transected. In order to achieve complete vagotomy, further fine branches have to be searched out and, if found, also divided.     

Comparison of radiological procedures in preoperative assessment of anchorage strength of spinal implants

PURPOSE: To compare three techniques with regards to their ability to estimate pull out strength of spinal fusion hardware. MATERIAL AND METHODS: VDS-screw fixation strength in 50 human cadaveric vertebral bodies was approximated by means of pull out force measurement. Bone quality was assessed by Dual X-ray Absorptiometry (DXA). Quantitative Computed Tomography (QCT) and T2*-relaxation time. For each of these techniques, correlation with axial pull out force strength was investigated. RESULTS: Highest correlation was found for cancellous bone density measured by QCT (r = 0.72; p < 0.001). Immediately followed by DXA (r = 0.70; p < 0.001), which involves all bone components. Inverted T2*-relaxation time (r = 0.55; p < 0.001) and cortical bone density (QCT) correlated just slightly with pull-out force strength. CONCLUSIONS: Absorptiometrical techniques like QCT and DXA are most appropriate to estimate VDS-screw fixation strength preoperatively.     

Thoracoscopic pleural tent

Lung volume reduction has been performed in patients with advanced emphysema to relieve dyspnea and improve exercise tolerance. Median sternotomy and video-assisted thoracoscopy have been proposed as equally adequate approaches; however, prolonged postoperative air leakage is the most prevalent complication in all series. For this reason, on the basis of the experience achieved with the median sternotomy approach, buttressing of the suture line with different materials and techniques for space reduction have been proposed. We describe a technique to create a pleural tent after thoracoscopic volume reduction. The thoracoscopic creation of a pleural tent is feasible and results in a duration of postoperative air leaks and hospital stays similar to that achieved with stapler line buttressing.     

Spontaneous thoracic spinal cord herniation through an anterior dural defect

A 44-year-old woman was examined for progressive left lower extremity weakness and spasticity. Thoracic spine MR imaging and CT myelography showed a ventral dural defect at T7-T8 with an extradural subarachnoid fluid collection and extradural herniation of the spinal cord. Intraoperative sonography confirmed the appropriate level for dural entry and the finding of spinal cord herniation. After reduction of the herniated spinal cord, the patient experienced gradual improvement in neurologic function.     

Radiological and functional outcome after anterior lumbar interbody spinal fusion

The efficacy of hCG treatment was studied in 182 cryptorchid patients. The efficacy of the treatment correlated with the initial position of the testis. None of the abdominal testes reached a normal position, whereas 90% of high scrotal testes descended during the treatment. Fifty-four boys who were treated unsuccessfully with hCG and 29 untreated boys were biopsied. The biopsies were performed on 32 scrotal and 87 maldescended testes to examine the state of the organ and the effects of hCG treatment. In biopsies, the volume densities of seminiferous tubules, interstitial tissue and blood vessels were counted, and the sections screened for interstitial bleeding. Significant differences between scrotal and maldescended testes were found in all of the volume densities measured. Interstitial bleeding occurred rarely in scrotal testes, whereas in maldescended testes it was frequently apparent. hCG treatment induced a significant increase in the volume density of both interstitial tissue and blood vessels. Even though the hCG treatment induced measurable, possibly harmful, changes both in scrotal and maldescended testes, our data do not prove that hCG treatment causes permanent damage to the testis.     

Urodynamically controlled management of spinal cord injury in children

Spinal cord injuries in children are relatively uncommon. However, infants with cervical spine injury have an especially high risk of renal damage. Six patients, 4 of them tetraplegic, aged 15 months to 8 years, were primarily treated by oral anticholinergic medication and intermittent catheterization. With this concept, satisfactory results were achieved in 4 of 6 children for a mean follow-up of 17.7 months. Mean bladder capacity increased by 128% and intravesical pressure was reduced by 35%. While all patients initially presented with a detrusor leak point pressure above 40 cm H2O, in 4 patients detrusor leak point pressure could be sufficiently reduced by initial treatment. One patient required intravesical instillation of oxybutynin; in another patient sphincterotomy was performed. No patient had signs of renal damage. In summary, even in tetraplegic infants, oral anticholinergic medication and intermittent catheterization is a safe and well-tolerated treatment.     

Thoracoscopic lobectomy in the animal model

To evaluate the possibility of a pure thoracoscopic lobectomy by preparation and selective division of hilar structures we performed left cranial lobectomies in 5 G?ttingen mini-pigs. The vessels and the main bronchus were isolated and divided by an Endo-GIA stapler. As an alternative technique we used clips or endoscopic ligation. Inside the thoracic cavity the resected lobes were divided into 2 or 3 parts by the Endo-GIA. They could be extracted without destroying the tissue therefore making macroscopic examination possible. The intraoperative blood loss was minimal and all the pigs survived the operation. Two pigs were sacrificed initially, the remaining three one month later. These three showed no evidence of pleural fistula or atelectasis in remaining lung tissue either macroscopically or histologically. It appears that thoracoscopic selective lobectomy is technically possible at least in pig studies. Further studies will show whether thoracoscopic lobectomy in patient with malignancy is as effective as open radical thoracotomy techniques and if endoscopic mediastinal division is possible.     

Rectal methohexital for sedation of children during imaging procedures

OBJECTIVE: Hypereosinophilic syndrome (eosinophilia without demonstrable cause) commonly involves eosinophilic infiltration of the liver and spleen, but few reports have described the imaging findings. Accordingly, we reviewed the imaging findings in five patients with this syndrome in whom the liver was involved. MATERIALS AND METHODS: Five patients who had hypereosinophilic syndrome with hepatic involvement were included in the study. The diagnosis of hepatic involvement was based on pathologic proof in two patients and on imaging and laboratory findings in the other three. Histologic examination of the hepatic lesions showed extensive eosinophilic infiltration in two patients and centrilobular necrosis in one. All patients had chest radiography, barium studies of the gastrointestinal tract, abdominal CT, and sonography. Four patients had hepatosplenic scintigraphy. All patients were followed up for 4-24 months. RESULTS: All patients had mild to marked hepatomegaly with multiple focal lesions. Focal lesions were detected on sonograms in three patients, on CT scans in four, and on scintigrams in three. On sonograms, the lesions were usually small (less than 2 cm in diameter), sharply or poorly defined nodules with varied echogenicity scattered throughout the liver. The lesions were hypodense with poorly defined margins on CT scans and appeared as variably sized areas of decreased radionuclide uptake on scintigrams. For each patient, the number, size, and shape of the lesions varied considerably from one imaging study to another. On follow-up studies 2-6 months after treatment, the appearance of the liver was normal. Other radiologic findings included transient pulmonary infiltrates (two patients), mild cardiomegaly (one patient), and mild lymphadenopathy (three patients). CONCLUSION: Hypereosinophilic syndrome is a cause of focal hepatic lesions seen on sonograms, CT scans, or scintigrams. The lesions are characterized by the varied appearance on the different types of images and the disappearance of the lesions with treatment.     

Giant somatosensory evoked potentials in a patient with the anterior spinal artery syndrome

We studied a previously healthy 25-year-old woman with the anterior spinal artery syndrome, a rare thoracocervical myelopathy with multiple potential etiologies. Quantitative and clinical sensory examination showed dissociated loss of pin-prick and temperature discrimination below the level of the lesion, with normal light touch, vibratory, and position sense. Magnetic resonance imaging was consistent with cervical spinal cord infarction. Median SEPs showed normal Erb's potential with absent spinal N13- and normal scalp N20- latency. Tibial SEPs showed normal lumbosacral responses and normal scalp P30- latency. Both median and tibial nerve stimulation produced cortical responses of unusually large amplitude (median 38 microV, tibial 17 microV). We hypothesize that large SEP amplitudes in this patient resulted from loss of anterolateral inhibitory influences on the dorsal column-medial lemniscal system.     

Thoracoscopic transmyocardial laser revascularization

Transmyocardial laser revascularization has been used to treat patients with end-stage coronary artery disease and severe disabling angina. Typically, the operative approach is through a left anterior thoracotomy. I report a case of transmyocardial laser revascularization performed thoracoscopically.