Giampiero Negri

Diagnosis and treatment of traumatic pulmonary pseudocysts.

BACKGROUND Traumatic pulmonary pseudocysts (TPPs) are rare sequelae of blunt chest trauma. We present a retrospective review of TPPs observed in our hospital and discuss the diagnosis, treatment, and complications of these unusual lesions. METHODS Between 1991 and 1999, 11 TPPs were diagnosed in 10 patients. None of the lesions was detectable on the chest radiograph obtained on the day of injury. In contrast, computed tomographic scan of the chest always demonstrated the TPPs. RESULTS In nine cases, spontaneous healing of the lesions was observed. One patient with a large lesion of the left lower lobe developed significant endobronchial bleeding and underwent successful emergency lobectomy. CONCLUSION TPPs are often missed by chest radiography, particularly when it is obtained in the supine position, whereas computed tomographic scan allows the identification of these lesions in all cases. TPPs are self-limiting, benign lesions that usually require no specific therapy. Surgical treatment is indicated in rare instances and only when complications occur.

Surgical treatment of catamenial pneumothorax: a single centre experience

We retrospectively reviewed our experience with catamenial pneumothorax (CP) in terms of treatment and follow-up. From 1993 to 2008, ten women presented at our department with CP. CP was right-sided in all patients: seven presented diaphragmatic defects including one endometriosis, five had apical bulla or blebs that in three patients were the only pathological findings. Surgical approach was thoracoscopic with a muscle-sparing thoracotomy when diaphragmatic defects where present. All patients underwent apical resection and apical pleurectomy associated in seven cases with diaphragmatic plication and chemical pleurodesis. After surgery nine patients underwent hormonal treatment: three were put on estrogen-progesterone complex treatment and six received gonadotropin-releasing hormone agonist (GnRH agonist). Recurrence rate was 40% and it was significantly correlated with estrogen-progesterone treatment (P<0.005). The mean follow-up was 52+/-32 months (range 14-168). At the present time, no recurrence has occurred in all women. Occurrence of CP is often underestimated. At the time of surgery the diaphragm should be carefully inspected for defects and/or endometriosis. Standard pleurodesis may not suffice and we suggest apical resection and apical pleurectomy associated with a diaphragmatic procedure when indicated. Hormonal treatment with GnRH agonist seems to improve the outcome.

Decortication for chronic parapneumonic empyema: Results of a prospective study

ABSTRACTDespite advances in diagnostic methods, surgical techniques, and supportive therapy, chronic parapneumonic empyema is still associated with considerable morbidity and mortality. A prospective study was performed on a consecutive series of patients with chronic parapneumonic empyema to analyze the results of surgical treatment and identify clinical predictors of poor outcome. From 1993 to 2000 a total of 40 patients underwent decortication for chronic parapneumonic empyema. There was no mortality. All 40 patients had definitive resolution of the empyema. Altogether, 34 patients (87.5%) had an uneventful postoperative course, and 5 (12.5%) experienced complications (2 prolonged febrile syndromes, 3 cases of sepsis requiring mechanical respiratory assistance). All complications resolved well with adequate treatment without further consequences. Definitive results of the surgical procedures assessed at the 6-month follow-up examination were good in 21 patients and satisfactory in 19. No unsatisfactory results were observed in any of the patients. Univariate analysis showed that three variables predicted morbidity: co-morbidities (p = 0.039), symptom duration ≥ 60 days (p = 0.009), and duration of preoperative conservative treatment ≥ 30 days (p = 0.006). Multivariate analysis showed that only symptom duration ≥ 60 days (p = 0.041) and duration of conservative treatment ≥ 30 days (p = 0.025) were associated with morbidity. Decortication is a highly effective treatment for chronic parapneumonic empyema and may be performed with low morbidity and mortality. Because prolonged duration of symptoms and conservative treatment increase morbidity, early surgical intervention seems to be the optimal modality for the treatment of chronic parapneumonic empyema.

Lower oesophageal sphincter hypersensitivity to opioid receptor stimulation in patients with idiopathic achalasia.

Impairment of non-cholinergic innervation of the lower oesophageal sphincter has been suggested in idiopathic achalasia. As opioid nerves are present in the lower oesophageal sphincter and opioid peptides affect lower oesophageal sphincter motility, the effect of an opioid agonist, morphine (100 micrograms/kg iv), and an opioid blocker, naloxone (80 micrograms/kg iv), on lower oesophageal sphincter motor function was assessed in 10 healthy subjects and in 10 patients with untreated idiopathic achalasia on separate days and in randomised order. In addition, in six of the patients, naloxone 0.8 mg iv was injected 60 minutes after morphine and recordings continued for a further five minutes. Lower oesophageal sphincter pressure was monitored by a sleeve device. In the healthy subjects morphine decreased (p < 0.01) resting lower oesophageal sphincter pressure by 4 (1) mm Hg (23 (8)%). In the achalasia patients the effect was more marked, lower oesophageal sphincter pressure being reduced (p < 0.01) by 11 (2) mm Hg (46 (8)%). Naloxone reversed lower oesophageal sphincter pressure to basal. Both absolute and percentage decreases after morphine were significantly greater (p < 0.05) in the achalasia patients than in the healthy subjects. Swallow induced lower oesophageal sphincter relaxation was significantly decreased (p < 0.05) by morphine in the healthy subjects but not in the achalasia patients. Naloxone had no effect on resting lower oesophageal sphincter pressure or swallow induced relaxation in either healthy subjects or achalasia patients. In conclusion achalasia patients are hypersensitive to the effect of morphine on resting lower oesophageal sphincter pressure. This finding is unlikely to be the result of a denervation process involving opioid nerves.

Conservative and Surgical Treatment of Acute Posttraumatic Tracheobronchial Injuries

BackgroundAcute posttraumatic tracheobronchial lesions are rare events associated with significant morbidity and mortality. They are caused by blunt and penetrating trauma, or they are iatrogenic, appearing after intubation or tracheotomy. Although surgery has traditionally been considered the treatment of choice for these injuries, recent reports show that conservative treatment can be effective in selected patients. The aim of this study was to evaluate the role of surgical and conservative management of these lesions, differentiated on the basis of clinical and endoscopic criteria.MethodsFrom January 1993 to October 2010, a total of 50 patients with acute posttraumatic tracheobronchial lesions were referred for treatment to our department. In all, 36 patients had iatrogenic injuries of the airway, and 14 had lesions resulting from blunt or penetrating trauma.ResultsOf the 30 patients who underwent surgery, the lesion was repaired with interrupted absorbable sutures in 29; the remaining patient, with an associated tracheoesophageal fistula, underwent single-stage tracheal resection and reconstruction and closure of the fistula. In all, 20 patients were treated conservatively: clinical observation in 5 patients, airway decompression with a mini-tracheotomy cannula in 4 spontaneously breathing patients, and tracheotomy with the cuff positioned distal to the lesion in 11 mechanically ventilated patients. One surgical and one conservatively-managed patient died after treatment (4% overall mortality). Complete recovery and healing were achieved in all the remaining patients.ConclusionsSurgery remains the treatment of choice for posttraumatic lesions of the airway. However, conservative treatment based on strict clinical and endoscopic criteria—stable vital signs; effective ventilation; no esophageal injuries, signs of sepsis, or evidence of major communication with the mediastinal space—enables favorable results to be achieved in selected patients.

Thoracoscopic techniques in the management of benign mediastinal dumbbell tumors.

Mediastinal dumbbell tumors can be resected with a variety of open surgical approaches. Recently, thoracoscopic techniques have been suggested for the treatment of benign neurogenic lesions. Over a 5-year period, three patients with a benign mediastinal dumbbell tumor were treated via a combined microneurosurgical and thoracoscopic approach. The neurosurgical phase consisted of a posterior laminectomy to free the tumor from the spinal cord, followed by an intervertebral foraminotomy. Thoracoscopic resection of the lesion was then performed in the same setting. The operative times were 240, 260, and 280 min, and there were no operative complications. The postoperative stays were 6, 7, and 7 days; the postoperative period was uneventful in all three patients. Pathologic examination revealed a benign schwannoma in two cases and an angiolipoma in one case. One patient reported the onset of paraesthesia in the left hypocondrium on the distribution area of the transected T10 and T11 intercostal nerves; slight paraesthesia still remains 15 months from surgery. We conclude that the combined posterior neurosurgical and thoracoscopic approach is a safe and effective method for the removal of benign mediastinal dumbbell tumors, whether neurogenic or nonneurogenic in origin.

Effect of loperamide on lower oesophageal sphincter pressure in idiopathic achalasia.

BACKGROUND We have recently shown that in achalasia patients morphine has a striking inhibitory action on resting lower oesophageal sphincter (LOS) pressure, which is mediated by opioid receptors. The aim of this study was to investigate the effect of a peripheral opioid agonist, loperamide, administered at a dose of 16 mg, on resting LOS pressure in nine patients with untreated idiopathic achalasia. METHODS All patients underwent two experiments after oral administration of placebo and loperamide, respectively, on separate days and in randomized order. At the end of the placebo experiment we also tested the effect of loperamide as compared with distilled water, both infused intraluminally at the level of the LOS. In the loperamide experiment, after a 60-min basal period, naloxone, 40 micrograms/kg, was injected intravenously, and recordings continued for a further 10 min. RESULTS Loperamide administered orally decreased (p < 0.01) LOS pressure by 10 +/- 2 mmHg (37 +/- 7%) compared with placebo, and naloxone intravenously failed to block the effect. LOS pressure was not affected by infusion of either distilled water or loperamide at the level of the LOS. CONCLUSIONS Our findings indicate that in patients with idiopathic achalasia oral administration of loperamide at a high dose markedly decreases resting LOS pressure. This may not occur through opioid receptor stimulation and requires intestinal absorption of the drug. The possible effect of combining a small dose of loperamide with the traditional achalasia drugs awaits further evaluation.

Early surgical repair of isolated traumatic sternal fractures using a cervical plate system.

BACKGROUND We reviewed our experience of the surgical management and follow-up of patients admitted with an isolated traumatic sternal fracture (TSF) to a Thoracic Surgical Unit through the Emergency Department. METHODS During a 5-year period, six patients were surgically treated for an isolated TSF. Presence of physical deformity or acute and persistent pain were considered indications for surgical repair. Surgical repair was performed within 1 week from the trauma by means of a titanium cervical plate system currently in use in spine surgery. RESULTS There were no postoperative complications. Mean hospital stay was 3 days. All patients showed regular sternal healing at 6 to 8 weeks. In one patient the plate was removed after 3 years because of persistent chest discomfort. CONCLUSIONS Early surgical repair of isolated TSF is advocated in cases of physical deformity or acute and persistent pain. The titanium cervical plate system provides effective repair of the fracture with satisfactory long-term results.

Mediastinal dumbbell angiolipoma

Nonneurogenic dumbbell tumors are rare. This report describes the case of a 46-year-old woman with a symptomatic mediastinal dumbbell angiolipoma. The tumor was successfully resected using a single-stage procedure, combining a posterior microneurosurgical and thoracoscopic approach. The patient made an uneventful recovery and the neurologic symptoms improved immediately.

Effectiveness and Safety of the Low-Molecular-Weight Heparin CY 216 in the Prevention of Fatal Pulmonary Embolism and Thromboembolic Death in General Surgery

Deep venous thrombosis is very frequent after general surgery, and its major complication, pulmonary embolism, is today the most frequent cause of postoperative death. The reduction of this cause of m