James W. Pate

Video-assisted thoracic surgery: Primary therapy for spontaneous pneumothorax?

BACKGROUND This study assessed the role of video-assisted thoracic surgery (VATS) in current therapy for spontaneous pneumothorax. METHODS We compared a retrospective series of 89 patients treated conventionally with a consecutive group of 30 patients undergoing VATS pleural abrasion. The 89 earlier patients were predominantly male (81%). Treatment groups included observation/aspiration (7 or 17%), tube thoracostomy (32 or 36%), multiple tubes (7 or 9%), and thoracotomy (43 or 48%). Of the 30 patients treated with VATS, 18 (66%) were male. Primary indications for operation were recurrent pneumothorax (17) and persistent air leak (9). RESULTS Hospital lengths of stay (LOS) for the earlier group were 5 days for simple tube and 7 days for primary thoracotomy; LOS for initial intervention followed by thoractomy exceeded 15 days in all subgroups. The average LOS in the VATS group was 13 days; 6 patients treated with primary VATS (no chest tube) had a mean LOS of 6.5 days. Complications included 3 (10%) prolonged air leaks (more than 7 days) and 2 (7%) early recurrences. CONCLUSIONS We do not recommend VATS as primary therapy for spontaneous pneumothorax; tube thoracostomy remains the treatment of choice. However, we strongly support surgical intervention early (3 days) in patients with a persistent air leak, and as primary therapy in a nonurgent situation if standard indications exist. This study shows no advantage of VATS over conventional thoracotomy in hospital stay or complication rate.

Medical management of acute traumatic rupture of the aorta

Surgical reconstruction is the treatment for acute traumatic aortic rupture and should be accomplished immediately in most patients. In patients in whom concomitant injuries or the development of life-threatening complications preclude safe and successful aortic reconstruction, pharmacological intervention to reduce the risk of free aortic rupture may be considered. Surgical reconstruction can then be more safely performed under controlled elective circumstances.

Noniatrogenic esophageal trauma

Few guidelines are available with which to facilitate treatment in patients with noniatrogenic injuries of the esophagus. Early diagnosis and proper management are essential if a good outcome is to be expected. In an effort to define better the treatment of patients with penetrating and blunt injuries of the esophagus, we report our recent 5-year experience at an urban trauma center. From July 1988 to June 1993, nineteen patients with esophageal perforations from penetrating (18) and blunt (1) trauma were identified by our trauma registry. There was no mortality in this group of patients and morbidity was mostly due to associated injuries. Eleven cervical esophageal injuries were repaired. One cervical injury was treated by stopping oral intake and giving intravenous antibiotics. The neck was not drained in 10 of the surgical cases. In 1 patient a tracheoesophageal fistula developed, which later was repaired with a pectoralis muscle flap. Seven perforations were identified in the thoracic (2) and abdominal (5) portions of the esophagus. All were due to gunshot wounds. In 4 cases, a fundal wrap was used to reinforce the repairs. Postoperative contrast studies confirmed that all repairs were intact. We conclude that penetrating and blunt tears of the esophagus can be repaired safely with minimal mortality. Morbidity is usually from associated injuries such as to the spinal cord and trachea. When identified early, cervical esophageal injuries do not need to be drained routinely.

Traumatic Rupture of the Aorta: Emergency Operation

Fifty-nine patients who had traumatic aortic rupture in the area of the isthmus and were treated less than one week after injury were studied. Most patients (N = 47) underwent repair using pump-oxygenator partial bypass; 7 had simple cross-clamping. Paraplegia developed in 4 during operation. One patient died of a head injury after receiving heparin for bypass. The experience with these patients and a critical review of the literature indicate that the use of extracorporeal circulation and avoidance of hypoxia and hypercapnia may decrease the probability of paraplegia. When laparotomy preceded thoracotomy, there were no clearly deleterious effects of heparinization.

Lower Esophageal Ring: Experiences in Treatment of 88 Patients

The lower esophageal ring is an unusual clinical disorder of the esophagus and consists of a thin submucosal circumferential scar that forms in the lower esophagus. It is probably an acquired lesion resulting from repeated insults to the lower esophageal mucosa. The symptom of dysphagia results from esophageal obstruction, and the degree of obstruction is directly related to the internal diameter of the ring. Episodic aphagia results from impaction of food at the site of the ring. Since 1970, 88 patients have been seen with either dysphagia or episodic aphagia. Sixty-five with chronic limited reflux were treated primarily by oral dilation. Two of them required an antireflux procedure at a later date because of accentuation of reflux symptoms. Eighteen patients received surgical treatment initially because of severe reflux disease. Treatment consisted of interruption of the ring combined with an antireflux procedure. Five patients received no treatment. Lower esophageal ring may be managed satisfactorily through oral dilation, resulting in relief of dysphagia. If reflux disease is present or is accentuated by dilation and cannot be controlled medically, then the appropriate antireflux procedure should be done.

Primary Aspergillus osteomyelitis of the sternum.

We report 2 cases of primary sternal osteomyelitis caused by Aspergillus; previously reported cases have been complications of sternotomy. Both patients were healthy young men with recent intravenous drug abuse. No other focus or predisposing factors were found. Both were treated with partial sternectomy and chondrectomy; 1 received long-term amphotericin B therapy. Both are doing well 2 1/2 years after operation. Drug usage, acquired immunodeficiency syndrome, and medical immunosuppression may lead to other cases.

OSTIUM SECUNDUM ATRIAL SEPTAL DEFECTS AND CONGESTIVE HEART FAILURE IN INFANCY.

Abstract Foramen secundum defects of the interatrial septum with large left to right shunts may cause congestive heart failure during infancy. In three infants with this lesion, varying in age from 5 days to 2 years, intractable congestive heart failure developed. Case 1 presented with signs of congestive heart failure in the newborn nursery. She failed to respond to the usual anticongestive measures. At 6 weeks of age her defect was reduced in size by the external closure technic of Sondergaard. She had an excellent postoperative course. Case 2 presented in severe congestive heart failure at 3 months of age. Clinical improvement followed ligation and division of a large patent ductus arteriosus. Signs of cardiac decompensation reappeared at 6 months. Closure of a secundum atrial septal defect on cardiopulmonary bypass was successful. The oldest child, a 2 year old female, presented with severe congestive heart failure of unknown duration. An attempt was made to close her atrial septal defect with cardiopulmonary bypass. Her death following surgery was apparently due to almost complete pneumonic consolidation of her lungs. Each of these female infants had distinctive physical findings which led to the correct clinical diagnosis of their lesion. In Case 2 the physical findings appeared after ligation and division of the patent ductus arteriosus. These physical signs were: a right ventricular systolic thrust along the lower left sternal margin, a harsh systolic ejection murmur along the left sternal border associated with a palpable systolic thrill, and a wide and fixed split of the second heart sound at the cardiac base. In addition to the physical findings, the electrocardiogram showed right atrial enlargement and right ventricular hypertrophy. Chest roentgenograms demonstrated moderate to marked heart enlargement with increased pulmonary blood floW. Our experience with these infants demonstrates again that foramen secundum interatrial septal defects may be lethal lesions and may be responsible for considerable morb dity during infancy. The gratifying postoperative course following partial closure of the defect of the atrial septum by the Sondergaard technic in the small infant suggests that this technic should be evaluated further as a palliative procedure for small infants in congestive heart failure caused by this lesion.

Rupture of a sinus of Valsalva aneurysm in an infant: Surgical correction∗

Abstract A newborn infant with rupture of an aneurysm of the right sinus of Valsalva had clinical and electrocardiographic evidence of this condition at birth. Only a diastolic murmur was present, and incorrect timing of this murmur, correlated with suggestive angiocardiographic findings, led to an erroneous diagnosis of severe congenital aortic stenosis. Surgical exploration revealed the true nature of the anomaly, and successful surgical correction was accomplished when the infant was 6 weeks of age. During subsequent follow-up, it was obvious that the patient had physical stigmata of Marfans syndrome and aortic insufficiency frequently described in association with this syndrome.

Prosthetic mitral valve replacement in children

Nine children with severe mitral valvular disease of varied etiologies had replacement oftheir valve with a Starr-Edwards ball-cage prosthesis. There was one death in the immediate postoperative period due to clot formation within the prosthesis, and one late death of unknown cause. The survivors have had dramatic symptomatic and objective evidence of postoperative improvement. The causes of mitral valvular disease in childhood are discussed, and the hazards of artificial valve implantation are weighed against the benefits of the procedure.

Combined gunshot injuries of the trachea and esophagus.

Abstract. During an 8-year period between 1985 and 1993, twelve patients were treated with combined gunshot wounds to the trachea and esophagus. All patients survived, but there were complications, including one tracheoesophageal fistula. Combined injuries of the trachea and esophagus should be repaired primarily, and drains do not necessarily have to be placed. The benefit of a muscle flap placed between the repairs was not confirmed in this series. Complications should be recognized early and treated aggressively to minimize damage to the airway.