Kamal Khalil

Pneumomediastinum: etiology and a guide to diagnosis and treatment

BACKGROUND Pneumomediastinum may be associated with mediastinal organ injury. The aim of this study was to identify predictive factors of mediastinal organ injury in patients with pneumomediastinum to guide diagnosis and treatment. METHODS A retrospective review was conducted including patients aged ≥18 years with Current Procedural Terminology code 518.1 (interstitial emphysema) from 2005-2011. RESULTS There were 279 of 343 patients (81%) with and 64 of 343 (19%) without history of trauma. In the trauma population, 13 patients (5%) were found to have mediastinal organ injuries, 10 (4%) had airway injuries, and 3 (1%) had esophageal injuries. In the nontrauma population, 36 patients (56%) had spontaneous pneumomediastinum, esophageal injuries were seen in 17 (27%), pneumothorax in 9 (14%), and airway injuries in 2 (3%). The predictors of esophageal injury were instrumentation (odds ratio [OR], 45.7; P < .0001), pleural effusion (OR, 10.5; P < .0001), and vomiting (OR, 9.3; P < .0001). Previous instrumentation was the most significant predictor of airway injury (OR, 9.05; P < .02). CONCLUSIONS Mediastinal organ injury in patients with pneumomediastinum is uncommon. Patients presenting with pneumomediastinum without a history of instrumentation, pleural effusion, or vomiting most commonly do not have mediastinal organ injuries.

Comparison of Biopsy-Proven Pneumocystis carinii Pneumonia in Acquired Immune Deficiency Syndrome Patients and Renal Allograft Recipients

Pneumonia unresponsive to antibacterial agents in patients with acquired immune deficiency syndrome (AIDS) has become a new indication for lung biopsy. In 14 patients, transbronchial or open-lung biopsy demonstrated Pneumocystis carinii. An additional 12 patients, who were immunosuppressed after renal transplantation, were seen with P. carinii pneumonia. The diagnosis was established by transbronchial biopsy in the majority of patients. All patients were treated initially with trimethoprim plus sulfamethoxazole. Pentamidine was added after diagnosis if improvement did not occur. Both groups demonstrated reversal in the T cell helper: suppressor ratio. We compared these two groups of immunocompromised patients with respect to clinical presentation, lung pathology, response to therapy, and survival. Patients with AIDS were seen with a two- to three-week prodrome of fever, lymphadenopathy, weight loss, and malaise followed by hypoxia and leukopenia within 12 hours. Transplant patients became acutely ill with fever and hypoxia within 24 to 36 hours. In both groups, chest roentgenogram showed bilateral diffuse infiltrates; sputum cultures were generally negative; and lung biopsy demonstrated Gomori-Jones periodic acid-methenamine-silver-positive P. carinii. Mortality was substantially higher in patients with AIDS (50% versus 8%). This difference may be explained by the fact that the T cell defect in AIDS has an infectious cause, while the defect in the renal allograft recipient is pharmacologically mediated.

Operative Intercostal Nerve Blocks With Long-Acting Bupivacaine Liposome for Pain Control After Thoracotomy

BACKGROUND Postthoracotomy pain is quite intense. Epidural analgesia (EPI) has long been the gold standard but is often associated with hypotension and urinary retention. The recent availability of liposomal bupivacaine formulation (Exparel) stimulated us to use it for multilevel intercostal nerve blocks (IB) injected during open thoracotomy. METHODS We reviewed the records of 85 patients who had open thoracotomies for lung, pleural, or mediastinal pathologies between March 2010 and December 2013. Clinical variables; pain score; supplemental narcotic utilization on day 1, 2, and 3; postoperative pulmonary complications; and hospital length of stay were compared in the 2 groups. RESULTS In all, 53 patients in the IB group had similar clinical data compared to 32 in the EPI group. There were statistically significant lower mean pain scores on days 1 and 3, but no significant difference in pain score on day 2. Supplemental narcotic utilization was not different between the 2 groups. There was a significant decrease in pulmonary complications in the IB group (4 of 53) compared to the EPI group (8 of 32).The total length of hospital stay was 7.4 days in the IB group versus 9.3 days in EPI group (p < 0.05). CONCLUSIONS It appears that intraoperative IB with bupivacaine liposome at 6 levels during thoracotomy provided significantly better pain control in postoperative days 1 and 3, compared to EPI in this retrospective study. This technique is simple, safe, and reproducible. It does not require epidural space invasion, infusion pumps, or another service to comanage the postoperative pain therapy.

A pilot study of a triple antimicrobial-bonded Dacron graft for the prevention of aortic graft infection

OBJECTIVE Perioperative infection of an aortic graft is one of the most devastating complications of vascular surgery, with a mortality rate of 10% to 30%. The rate of amputation of the lower limbs is generally >25%, depending on the graft material, the location of the graft and infection, and the bacterial virulence. In vitro studies suggest that an antibiotic-impregnated graft may help prevent perioperative graft infection. In a pilot animal study, we tested a locally developed technique of bonding Dacron aortic grafts with three antimicrobial agents to evaluate the ensuing synergistic preventive effect on direct perioperative bacterial contamination. METHODS We surgically implanted a 6-mm vascular knitted Dacron graft in the infrarenal abdominal aorta of six Sinclair miniature pigs. Two pigs received unbonded, uninoculated grafts; two received unbonded, inoculated grafts; and two received inoculated grafts that were bonded with chlorhexidine, rifampin, and minocycline. Before implantation, the two bonded grafts and the two unbonded grafts were immersed for 15 minutes in a 2-mL bacterial solution containing 1 to 2 × 10(7) colony-forming units (CFU)/mL of Staphylococcus aureus (ATCC 29213). Two weeks after graft implantation, the pigs were euthanized, and the grafts were surgically excised for clinical, microbiologic, and histopathologic study. RESULTS The two bonded grafts treated with S aureus showed no bacterial growth upon explant, whereas the two unbonded grafts treated with S aureus had high bacterial counts (6.25 × 10(6) and 1.38 × 10(7) CFU/graft). The two control grafts (unbonded and untreated) showed bacterial growth (1.8 × 10(3) and 7.27 × 10(3) CFU/graft) that presumably reflected direct, accidental perioperative bacterial contamination; S cohnii ssp urealyticus and S chromogenes, but not S aureus, were isolated. The histopathologic and clinical data confirmed the microbiologic findings. Only pigs that received unbonded grafts showed histopathologic evidence of a perigraft abscess. CONCLUSIONS Our results suggest that bonding aortic grafts with this triple antimicrobial combination is a promising method of reducing graft infection resulting from direct postoperative bacterial contamination for at least 2 weeks. Further studies are needed to explore the ability of this novel graft to combat one of the most feared complications in vascular surgery.

Adenoid Cystic Carcinoma of the Thymus Gland: A Rare Tumor

Thymic carcinomas are rare malignant neoplasms. We present a case of adenoid cystic carcinoma of thymus in a 65-year-old woman that was initially misdiagnosed and was treated as non-small cell carcinoma of the lung. We describe the clinical and pathologic features of this extremely rare thymic epithelial tumor, with survival at 2 years and 6 months of follow-up.

Intrathoracic esophageal perforation with the Angelchik antireflux prosthesis: report of a new complication.

Esophageal perforation associated with migration of an Angelchik antireflux prosthesis into the thorax is reported. After initial nonoperative management, this patient was treated by an esophagogastrectomy with a favorable outcome. The complications associated with this prosthesis are reviewed briefly.

Unusual Sequelae of Colon Interposition for Esophageal Reconstruction: Late Obstruction Requiring Reoperation

Colon interposition has become a favored technique for esophageal reconstruction. Late morbidity is generally related either to technical problems associated with the procedure or to the development of new disorders in the transposed segment. Two patients are discussed who were seen with obstruction of colon interposition grafts ten and five years after esophageal reconstruction. In the first patient, a volvulus of the interposed colon associated with a chronically narrowed area distal to the looped segment resulted in obstruction. In the second patient, the redundant intrathoracic segment of the colon interposition became kinked at the diaphragmatic hiatus leading to dilatation and incomplete emptying. Both patients underwent successful reoperations and are doing well 10 and 12 months later. The causes and possible prevention of these and other late complications of colon interposition are discussed.

Aortic intimal sarcoma: report of two cases with immunohistochemical analysis for pathogenesis

Primary vascular neoplasms are rare entities. They were first described as arising spontaneously in the aorta and other vessels. However, in the past several decades, a number of systemic artery-derived vascular neoplasms, mostly sarcomas, have been reported as arising in intimate association with synthetic grafts. We describe two additional cases of intimal sarcoma seen at our institution. The first is an invasive intimal sarcoma detected in a thoracoabdominal aortic aneurysm at the time of surgical intervention. The second is a superficial spreading intimal sarcoma associated with a Dacron-coated graft, in place for 9 years, detected when the graft was replaced. When the patient died 3 months later, a metastatic subcutaneous sarcomatous lesion was detected at autopsy. In these cases, we studied selective molecular pathways that may be involved in the transformation of benign endothelium to malignant endothelium, with implications for possible therapeutic targets. These cases are presented in order to contribute additional data to the literature involving these vascular neoplasms and to potentially provide a spectrum of disease seen in the vasculature tissues that may arise spontaneously or after placement of a synthetic graft.

Successful Multistaged Surgical Management of Secondary Aortoesophageal Fistula With Graft Infection.

Secondary aortoenteric fistula is a rare and dreaded complication of aortic graft replacement. This case demonstrates successful management of a patient with thoracic aortic graft infection resulting in aortoesophageal fistula and the feasibility of combined endovascular approach as a temporary measure to stabilize the patient in extremis, followed by a definitive surgical repair. The patient had a remote history of descending aortic repair and an emergent thoracic endovascular aortic repair for upper gastrointestinal bleeding 2 months ago. We performed a three-staged operation involving extraanatomic bypass, total infected aortic graft excision, and primary closure of the esophageal perforation with muscle flap coverage, from which he eventually recovered.

Endovascular management of pulmonary artery stenosis due to tumor compression.

A 75-year-old man with invasive thymoma encasing the aortic arch and pulmonary arteries was referred to our institution with a 1-year history of dyspnea and worsening right heart failure. Pulmonary angiogram demonstrated greater than 90% stenosis of the right pulmonary artery. Balloon angioplasty and stent placement were performed with immediate improvement in his shortness of breath and peripheral edema. Improved lung opacification was noted on completion arteriography, and the stents remained patent until the patient expired from complications related to his cancer 2 years later. Pulmonary artery stenting in noncongenital causes of stenosis is a safe and effective therapy.