Lynn S. Broderick

Reexpansion pulmonary edema

Reexpansion pulmonary edema is a rare complication attending the rapid reexpansion of a chronically collapsed lung, such as occurs after evacuation of a large amount of air or fluid from the pleural space. The condition usually appears unexpectedly and dramatically—immediately or within 1 h in 64% of patients and within 24 h in the remainder. The clinical manifestations are varied; they range from roentgenographic findings alone in asymptomatic patients to severe cardiorespiratory insufficiency. The radiographic evidence of reexpansion pulmonary edema is a unilateral alveolar filling pattern, seen within a few hours of reexpansion of the lung. The edema may progress for 24–48 h and persist for 4–5 days. Human data on the pathophysiology of reexpansion pulmonary edema derive from small series of patients, case reports, and reviews of the literature. On the other hand, a larger body of data exists on experimental reexpansion pulmonary edema in cats, monkeys, rabbits, sheep, and goats. This review examines the clinical and experimental evidence for reexpansion pulmonary edema. In addition, we detail the historical background, clinical setting, treatment, and outcome of reexpansion pulmonary edema.

Aggressive surgical management of sternoclavicular joint infections

BACKGROUND Although the sternoclavicular joint is an unusual site for infection, thoracic surgeons may preferentially be called on to coordinate management of cases refractory to antibiotic therapy because of the anatomic relationship of this joint to major vascular structures. METHODS Since 1994 we have surgically managed nine sternoclavicular joint infections in eight patients. Associated medical problems were frequent and included diabetes mellitus (n = 2), end-stage renal disease (n = 2), hematologic disorders (n = 2), and multiple joints affected by sepsis (n = 4). Open joint exploration with drainage and débridement with the use of general anesthesia was performed in four patients. The remaining four patients (one with bilateral sternoclavicular joint infections) had computed tomographic evidence of diffuse joint and surrounding bone destruction with infection extending into mediastinal soft tissues. Surgical therapy for these five joint infections involved en bloc resection of the sternoclavicular joint with an ipsilateral pectoralis major muscle covering the bony defect. RESULTS There were two deaths unrelated to the surgical procedure. After a mean follow-up of 20 months, the remaining six survivors (seven joints) have complete healing with no apparent limitation in the range of motion even after en bloc resection. CONCLUSIONS Most cases of early sternoclavicular joint infections will respond to conservative measures. However, when radiographic evidence of infection beyond the sternoclavicular joint is present, en bloc resection, although seemingly aggressive, results in immediate eradication of all infection with negligible functional morbidity. Prolonged antibiotic therapy or continued local drainage procedures appear to have little value in these cases, adding only to patient care costs and the potential sequelae of chronic infections.

CT evaluation of normal interatrial fat thickness

PURPOSE This study was performed to determine the normal thickness of fat in the interatrial septum as demonstrated by CT. METHOD Eighty-seven subjects underwent helical chest CT examination as part of a separate protocol to compare the quantification of coronary artery calcification by CT to coronary angiographic findings, using a slice width of 3 mm, reconstructed every 1.5 mm. The thickness of the interatrial fat in both groups was measured anterior and posterior to the fossa ovalis. The mean and standard deviation were calculated. RESULTS The mean thickness of interatrial fat anterior and posterior to the fossa ovalis was 4.6 (SD = 2.5) and 3.7 (SD = 3.1) mm, respectively. CONCLUSION The normal range of thickness of the interatrial fat is 0-9.6 mm anterior to and 0-9.9 mm posterior to the fossa (2 SD above the mean).

Bronchoperitoneal fistula secondary to chronic Klebsiella pneumoniae subphrenic abscess

We treated a case of bronchoperitoneal fistula secondary to a Klebsiella pneumoniae subphrenic abscess. This fistulous communication and the surgical procedure used to treat it are described.

Image-guided coaxial fine needle aspiration biopsy with a side-exiting guide.

Purpose The aim of this study was to evaluate the diagnostic accuracy and complication rates of a side-exiting coaxial needle system for fine needle aspiration (FNA) biopsies. Method Between 1995 and 1998, 127 nonconsecutive biopsies were performed on 122 patients (74 males, 48 females). CT guidance was used in 111, ultrasound guidance was used in 14, and both were used in 2 biopsies. Patient history, biopsy site, needle performance, complications, and cytology results were recorded. Results Diagnostic rate and accuracy were 92.9 and 99.2%, respectively. There were minor complications from 14 biopsies, and all of them arose from chest biopsies: pneumothorax in 13 of 47 and hemoptysis in 1 of 47. There were no major complications. Conclusion The side-exiting coaxial needle system is a safe and effective alternative to the conventional end-exiting coaxial needle system for performance of image-guided FNA biopsies.