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BACKGROUND: Aim of the study was to assess the results of surgery for secondary spontaneous pneumothorax (SSP) in the elderly with COPD at Shanghai Pulmonary Disease Hospital. METHODS: From 1 January 1993 to 30 June 2007, the operation for SSP was performed in 107 elderly patients (??60y) with COPD. All patient data was reviewed retrospectively. RESULTS: Morbidity was 25.2?% and mortality was 4.7?%. The total effective rate of intrapleural injection of human fibrinogen for the treatment of postoperative persistent air leaks was 86.7?%. Multivariate analyses of postoperative air leaks suggest that patients undergoing pleurodesis (OR 0.189, 95?% CI 0.045-0.790, P?=?0.022) have a decreased risk of postoperative air leaks. Multivariate analyses of postoperative complications suggest that patients with higher PaCO 2(OR 0.890, 95?% CI 0.814-0.973, P?=?0.011) have an increased risk and patients undergoing pleurodesis (OR 4.319, 95?% CI 1.398-13.349, P?=?0.011) have a decreased risk. CONCLUSIONS: Surgical intervention is recommended in selected elderly COPD patients with SSP, with hypercapnia known as an operative contraindication. Additionally, surgery offers the advantage of intraoperative pleurodesis for the prevention of prolonged postoperative air leaks, while intrapleural injection of human fibrinogen is an effective procedure in the treatment of air leaks. [ABSTRACT FROM AUTHOR]

Abstract: Objective: Creation of a patent subglottic airway after partial cricotracheal resection (PCTR) may not always result in successful decannulation due to associated parameters such as co-morbidity and/or glottic involvement. We classified patients after incorporating these additional parameters into the original Myer–Cotton classification to assess whether this could better predict the outcome measures after PCTR. Methods: One hundred children with Myer–Cotton grade III or IV subglottic stenosis who underwent PCTR between 1978 and 2008 were identified from a prospectively collected database. The patients were classified into four groups based on the association of co-morbidity and/or glottic involvement. Delay in decannulation, revision open surgery and rates of decannulation were the outcome measures compared between the groups. Results: There were 68 children with Myer–Cotton grade III and 32 children with grade IV stenosis. Based on the new classification, there were 36 children with isolated SGS, 31 with associated co-morbidity, 19 with associated glottic involvement and 14 children with both co-morbidity and glottic involvement. A trend towards less optimal results was noticed with the association of co-morbidity and/or glottic involvement. Statistical significance was reached for maximum decannulation failure in the group with both co-morbidity and glottic involvement. Delayed decannulation significantly correlated in the group with associated glottic involvement. Conclusion: This new classification is relatively simple and aimed at providing more accurate and uniform prognostic information to both patients and surgeons when dealing with the whole spectrum of severe SGS. [Copyright &y& Elsevier]

Abstract: Background: The term occult pneumothorax (OP) describes a pneumothorax that is not suspected on the basis of either clinical examination or initial chest radiography, but is subsequently detected on computed tomography (CT) scan. The optimal management of OP in the blunt trauma setting remains controversial. Some physicians favour placement of a thoracostomy tube for patients with OP, particularly those undergoing positive pressure ventilation (PPV), while others favour close observation without chest drainage. This study was conducted both to determine the incidence of OP and to describe its current treatment status in the blunt trauma population at a Canadian tertiary trauma centre. Of interest were the rates of tube thoracostomy vs. observation without chest drainage and their respective outcomes. Methods: A retrospective review was conducted of the Nova Scotia Trauma Registry. The data on all consecutive blunt trauma patients between October 1994 and March 2003 was reviewed. Outcome measures evaluated include length of stay, discharge status—dead vs. alive, intervention and time to intervention (tube thoracostomy and its relation to institution of PPV). Direct comparison was made between the OP with tube thoracostomy group and OP without tube thoracostomy group (observation or control group). They were compared in terms of their baseline characteristics and outcome measures. Results: In 1881 consecutive blunt trauma patients over a 102-month period there were 307 pneumothoraces of which 68 were occult. Thirty five patients with OP underwent tube thoracostomy, 33 did not. Twenty nine (82.8%) with tube thoracostomy received positive pressure ventilation (PPV), as did 16 (48.4%) in the observation group. Mean injury severity score (ISS) for tube thoracostomy and observation groups were similar (25.80 and 22.39, p =0.101) whereas length of stay (LOS) was different (17.4 and 10.0 days, p =0.026). Mortality was similar (11.4% and 9.1%). There were no tension pneumothoraces. Conclusion: The natural history of OP in blunt trauma patients at our institution appears to be one of uneventful resolution irrespective of ISS, need for PPV, or placement of tube thoracostomy. This study suggests an interesting hypothesis that observation of the blunt trauma patient with OP, without tube thoracostomy, may be safe and contribute to a shorter hospital stay. These are observations that would benefit from further study in a large, prospective randomised controlled trial. [Copyright &y& Elsevier]

We report herein two cases of carcinoma of the cervical esophagus adjacent to the larynx in which surgery achieved good results. Surgery for case 1, a 64-year-old woman, comprised resection of a carcinoma of the cervical esophagus at stage 0-IIa T1aN0M0, bilateral neck and paratracheal dissections (D1 and D2 dissection), reconstruction using the free jejunal segment, and tracheostomy. At 30 days postoperatively, she was able to eat normal food. For case 2, a 58-year-old man, the same operative procedures were conducted for stage 0-IIc T1bN0M0 carcinoma. At 33 days postoperatively, the patient was able to eat rice porridge (5 parts water, 1 part rice). We therefore consider that for carcinomas in the vicinity of the pharyngoesophageal segment, surgery can achieve both radical cure and preservation of function in some cases. [ABSTRACT FROM AUTHOR]

Summary: There is an increasing use of large airway stents for non-malignant disease processes. As advances in stent development and manufacture are made, there are more patients being treated with airway stents. Stenting can be short term or long term and can be used for the management of large airway obstruction where surgery carries both morbidity and mortality. Pre-operative assessment is particularly important and may determine which of the wide range of techniques that have been used is most appropriate for the individual case. The anaesthetic management of patients with stents already in situ is becoming more important as the number of patients with stents increases. There are some specific pitfalls and problems associated with anaesthesia and these are reviewed. [Copyright &y& Elsevier]

Abstract: Objective: The purpose of this study was to examine the feasibility of conducting aerodynamic and acoustic assessment in children following airway reconstruction. Underlying etiologies, co-morbidities and age related factors can present challenges for meaningful instrumental data collection in this population. Methods: A chart review of 100 children who were seen for a complete voice evaluation at the Center for Pediatric Voice Disorders at the Cincinnati Children''s Hospital Medical Center was conducted. Children who completed full or partial aerodynamic and acoustic protocols were identified. Data regarding the ability to participate in the assessment was tabulated, and vowel samples taken from the acoustic data were subjected to signal type classifications (e.g., Type I, II, III). Results: Fifty-three children met the inclusion/exclusion criteria of the chart review. Of those children, 58% (n =31/53) were able to complete the full acoustic and aerodynamic protocols without any modification. In regards to the aerodynamic protocol alone, 64% (n =34/53) could complete protocol. In regards to the acoustic protocol alone, 75% (n =40/53) could complete the entire acoustic protocol without any modification. There were 32% (n =17) who provided a Type I acoustic signal which was appropriate for measurement of F 0. There was a significant correlation between age and ability to complete the protocol for both the aerodynamic (p =.007) and acoustic (p =.004) protocols. Conclusions: This study demonstrated that a majority of children were capable of completing aerodynamic and acoustic protocols. A significant proportion of children in this study had severe dysphonia, precluding the ability to extract fundamental frequency. Although aerodynamic and acoustic measures are feasible for many patients in this population, the severity of dysphonias observed in these patients causes the use of these measures to be limited in some cases for documenting behavioral and surgical outcomes measures. [Copyright &y& Elsevier]

Abstract: Persistent respiratory symptoms often occur after double aortic arch (DAA) repair but rarely require a second operation. We report 4 children with severe respiratory problems (failure to extubate, 2; severe respiratory distress, 2) caused by severe tracheomalacia and tracheal compression after DAA repair, treated by anterior aortopexy. Aortopexy proved effective and safe in improving symptoms and provides a simple treatment option for children with severe malacia or tracheal compression after DAA repair. [Copyright &y& Elsevier]

Abstract: The cone-beam CT (CBCT), which is acquired using an on-board imager (OBI) attached to a linear accelerator, is used effectively in the verification of setup accuracy for lung radiation surgery. In this study, the respiratory organ motional effect on the CBCT was evaluated with a properly devised phantom system, and the level of possible error in conditions of a real clinical process was assessed. In a comparison study between the CBCT in static status and CBCT images acquired in 20 different motional cases, we confirmed that the image quality and information of CBCT were degraded, with an increase of motional ranges in the region of inhomogeneous structures. The 4D-CT MIP (50∼55%) for the planning of lung radiation surgery and the 4D-CT MIP (full phase) were compared with CBCT in the various motional cases for the evaluation of the influence of the motional effect on CBCT in the process of the setup error correction. The average ratio of relative difference between plan CT: 4D-CT MIP (50%∼55%) and CBCT was 5.79% and between plan CT: 4D-CT MIP (50%∼55%) and 4D-CT MIP (full phase) was 42.95% in the phantom study. In the analysis of clinical cases of lung radiation surgery, the gross tumor volumes were compared in each CT image. The average ratio of relative difference between plan CT: 4D-CT MIP (50∼55%) and CBCT was 10.72% and between plan CT: 4D-CT MIP (50∼55%) and 4D-CT MIP (full phase) was 28.19%. These results showed that, although a respiratory organ motional effect on CBCT introduced variation in image quality, the error as a result of this variation could be estimated relatively low in the setup error correction for a gated-lung radiation surgery when the planning was performed in 4D-CT MIP (50∼55%), which already included a related signal of motional effect. [Copyright &y& Elsevier]

Upper airway constriction is an important contributing factor to obstructive sleep apnea (OSA), which may be treated in a palliative manner with mandibular advancement devices (MADs) to increase patency of the airway. It may be the treatment of choice for affected individuals who cannot use a continuous positive airway pressure device or who are not candidates for surgical correction of OSA. The specific distance applied during mandibular advancement, however, is often arbitrarily determined. This project uses cone beam computed tomography imaging in patients with OSA to determine a quantifiable relationship between airway patency and mandibular advancement. This correlation may be the basis to create an ideal technique to diagnose and treat patients having OSA. Twenty-six subjects successfully treated for OSA with a MAD received 2 cone beam computed tomography scans; 1 with and 1 without the MAD. Volumetric, cross-sectional, and cephalometric measurements were gathered from these scans. With the use of linear regression statistical analysis, specific predictor parameters have been identified for volumetric and cross-sectional airway information. An average oropharyngeal volume increase of approximately 2800 mm3 was achieved with MAD therapy. [Copyright &y& Elsevier]

The amelioration of obstructive sleep apnea syndrome (OSAS) by maxillomandibular advancement (MMA) surgery can be predicted by analyzing anatomical airway changes with 3-dimensional (3D) geometrical reconstruction and computational fluid dynamics. Computer Enabling Technology Lab (ETLab) and Computational Simulation Lab (CSLab) can be used to analyze anatomic airway change for previously operated patients with a clinical cure of OSAS. MMA surgery reduces airway resistance and pressure effort (gradient) of OSAS by increasing the dimension of the airway. ETLab has been used to reconstruct the upper airway as a 3D computer model (bone and soft tissue surrounding the pharyngeal airway) from existing helical computed tomography scan format of OSAS patients. ETLab can compare and construct the geometry with numerical meshes of the airway between pre- and postoperative MMA by the use of bioengineering software. This technology uses high-fidelity computation fluid dynamic simulations, developed at the CSLab, for prediction and analysis of the flow field in the airway for pre- and postoperative MMA. It is possible to use the simulation to predict the likely success of future treatment and develop a prognostic factor. The soft- and hard-tissue mesh is used to determine the pre- and postoperative differences in the facial and pharyngeal tongue base for soft-tissue change associated with hard-tissue movement. This correlation predicts the amount of surgical movement necessary to create an adequate airflow. These results help define the surgical techniques in OSAS for more precise identification of upper airway anatomical features. This process correlates the area and pressure change at the velopharynx, oropharynx, and retroglossal space of the upper airway by the ETLab. Results can compare with polysomnogram and cure rates. 3D computer analysis can be used to test flow dynamics in the human airway for surgical treatment of OSAS. [Copyright &y& Elsevier]

Some of the most severe forms of obstructive sleep apnea are attributed to anatomic abnormalities in the facial skeleton. With the use of conventional orthognathic surgical techniques, it is possible to expand the posterior airway. In fact, there is strong evidence in the literature to support maxillomandibular advancement as one of the most efficacious surgical procedures for the treatment of obstructive sleep apnea (OSA). There are complications associated with this procedure but these are minor when compared with the risk of inadequately treated OSA. [Copyright &y& Elsevier]

Obstructive sleep apnea (OSA) syndrome is a serious health problem that affects a large number of individuals. Research in the field has improved our understanding of the disease, and a holistic management of the OSA patient is becoming widely adopted. When continuous positive airway pressure (CPAP) and dental appliance have failed, surgical procedures to improve the posterior airway are performed. When chosen correctly, these procedures have tremendous benefit to the airway and can potentially cure this devastating syndrome. [Copyright &y& Elsevier]

The benefit of bullae ablation for the management of primary spontaneous pneumothorax (PSP) has been established. However, various modalities for bullae ablation have been reported from different centers. The present study aimed to assess whether endoloop ligation of bullae was as effective as staple bullectomy for preventing the recurrence of pneumothorax. Between January 1993 and December 2003, 226 patients (203 men and 23 women) with PSP were recorded and retrospectively reviewed. One hundred thirty (57.5%) patients were treated with endoloop ligation of bullae and the other 96 (42.5%) were treated with staple bullectomy. Mechanical abrasion was performed in all patients after bullae ablation. The recurrence rate of pneumothorax was 6.2% (8 patients) in the endoloop ligation group and 17.7% (17 patients) in the staple bullectomy group ( p = 0.006). The postoperative complication rate was 14.6 and 20.8% in the endoloop ligation and staple bullectomy groups, respectively ( p = 0.221). The long-term chest discomfort rate after endoloop ligation and staple bullectomy was 14.6 and 13.5%, respectively ( p = 0.819) Endoloop ligation of bullae is as effective as mechanical staple bullectomy for the management of bullae in primary spontaneous pneumothorax. [ABSTRACT FROM AUTHOR]

Abstract: At present, the deployment of self-expandable braided stents has become a common and widely used minimally invasive treatment for stenotic lesions in the cardiovascular, gastrointestinal and respiratory system. To improve these revascularization procedures (e.g. increase the positioning accuracy) the optimal strategy lies in the further development of the stent design. In the context of optimizing braided stent designs, computational models can provide an excellent research tool complementary to analytical models. In this study, a finite element based modelling strategy is proposed to investigate and optimize the mechanics of braided stents. First a geometrical and finite element model of a braided Urolume endoprosthesis was built with the open source pyFormex design tool. The results of the reference simulation of the Urolume stent are in close agreement with both analytical and experimental data. Subsequently, a simplex-based design optimization algorithm automatically adjusts the reference Urolume geometry to facilitate precise positioning by reducing the foreshortening with 20% while maintaining the radial stiffness. Therefore, the proposed modelling strategy appears to be a promising optimization methodology in braided stent design. [Copyright &y& Elsevier]

The article describes clinical transplantation of a tissue-engineered airway. Using a tissue-engineering protocol, tubular tracheal matrices were bioengineered. Major histocompatibility complex antigens and cells were removed from human donor trachea and were colonised with epithelial cells and mesenchymal stem-cell-derived chrondrocytes cultured from cells of a 30 year old patient chosen to be the recipient. The patient's left main bronchus was replaced with the graft which provided a functional airway. Researchers explain that the woman had no anti-donor antibodies. They concluded that a cellular, tissue-engineered airway which provides normal functioning and has no risk of rejection may be produced.

Background: The problem of how to treat large tracheal lesions remains a challenge in surgery. To reconstruct a long tracheal defect, a safe method other than end-to-end anastomosis is necessary. Materials and methods: In 14 adult cross-breed dogs, a segment of trachea including seven tracheal rings was dissected and resected circumferentially. A submuscular tunnel was induced between mucosal and muscular layers of the adjacent esophagus lying right next to the trachea. An endotracheal tube was inserted between the tracheal rings 2 and 3. Then it was passed cautiously through the esophageal submuscular tunnel and through the distal tracheal segment. The proximal and distal ends of the esophageal tunnel and trachea were approximated and anastamosed. The animals were extubated 10 days after the operation. Results: All dogs tolerated the surgical procedure well. The first two dogs experienced postoperative fever, tracheoesophageal fistula, aspiration pneumonia, and sepsis so hard bony components were omitted from diet. All survived animals were eating and barking well. The submuscular esophageal tunnel was patent in all animals. The new lumen was supported externally with fibrous connective tissue. The tunnelized area was covered completely with pseudostratified ciliated epithelium. Conclusion: Due to formation of fibrous tissue between skeletal muscular structures of the neck and the external layer of the tunnelized esophagus, the new airway remained patent. Overall, air tightness, good reepithelialization, and relatively no limitation of esophageal length are the advantages of tracheal reconstruction by submuscular esophageal tunneling. This new method is worthy of further investigation, as it is technically feasible and easy to implement. [Copyright &y& Elsevier]

Abstract: Gas exchange is the main function of the lungs. Oxygen and carbon dioxide diffuse along the gradient of their partial pressures across the alveolar capillary membrane. Lungs have a vast area for gas exchange. Alveolar ventilation and pulmonary circulation are closely interlinked to provide efficient gas exchange in the lungs. This means that gas exchange can be impaired after surgery and in various disease states, leading to hypoxia. Hypoxaemia often results from ventilation–perfusion () mismatching and an increase in fractional inspired oxygen (F i o 2) does not fully correct it. A reduced transfer factor for carbon monoxide (TLCO) indicates disease of the pulmonary parenchyma or pulmonary circulation. Various tests are available to assess the pulmonary function including gas exchange. These tests can be used for the purposes of diagnosis, follow-up and fitness for undergoing anaesthesia and surgery. [Copyright &y& Elsevier]

Objective To evaluate the criteria for the insertion and correct placement of the laryngeal mask airway (LMA) in dogs. Study design Prospective descriptive clinical study. Animals Thirty healthy dogs (ASA I or II) of different breeds, age 0.33–7.0 years (2.8 ± 2.1; mean ± SD), weight 2.2–59.0 kg (23.9 ± 14.4), anaesthetized for elective surgery. Materials and methods The dogs were sedated with intravenous (IV) medetomidine (10 μg kg−1) and butorphanol (0.2 mg kg−1). If considered necessary, IV propofol (1 mg kg−1 over 30 seconds) was administered until the LMA was inserted and positioned correctly. The position of the LMA was evaluated using predefined criteria for its insertion and inflation of the cuff, together with the ability to ventilate the dogs through the LMA. Results The criteria for insertion, inflation and ventilation which indicated a clinically optimal position of the LMA and its seal around the larynx were met in 19 dogs (63.3%). The dogs could be manually ventilated with inspiratory peak pressures of 10 cm H2O without capnographic or audible evidence of leakage. In 11 dogs (36.7%), the LMA was positioned suboptimally with leakage during manual ventilation with inspiratory peak pressures not exceeding 10 cmH2O. There was no evidence of breed-related differences in LMA placement and position. Conclusions and clinical relevance The technique for the insertion of the LMA using predefined criteria to evaluate a correct positioning and a seal led to a successful placement in dogs of both brachycephalic and nonbrachycephalic breeds. The LMA, in most of the dogs, was easily placed, well tolerated and offered a useful less invasive means of securing the upper airway. [ABSTRACT FROM AUTHOR]

Abstract: Objective: Residual air spaces on chest radiographs after pneumothorax surgery are not uncommon. We aimed to study their incidence and impact on surgical outcomes. Methods: Four hundred and twenty-seven patients [283 men and 144 women with a median age of 31 (14–96) years] underwent surgery for pneumothorax from 1995 to 2005 in a single unit. Video-assisted thoracoscopy was used in 225 cases (53%). Outcomes were: duration of intercostal drainage and hospital stay, recurrence, re-operation and referral to chronic pain clinic. Results: Median duration of intercostal drainage and hospital stay were 5 and 6 days, respectively. We found a recurrence rate of 6.6% (n =28), re-operation rate of 2.8% (n =12) and need for referral to pain clinic of 7% (n =30). In 129 patients (30%) a small residual apical space (RAS) was reported on chest radiograph prior to discharge. Hospital stay and duration of drainage were longer in these cases (p =0.002 and 0.02, respectively). On multivariate analysis RAS on chest radiograph was associated with increased risk of recurrence [hazard ratio 3.1 (1.4–6.8 95% CI)] (p =0.005); but no need for re-operation or referral to pain clinic. Re-operation was associated with VATS surgery (p =0.001) and when no abnormalities were identified at operation (p =0.04). Referral to pain clinic was more common after open surgery (p =0.01). Discussion: The risk of recurrence after pneumothorax surgery is low. But the presence of a residual apical space on chest radiography after surgery increases it significantly. Recurrence may be due to the failure to achieve early pleural symphysis. [Copyright &y& Elsevier]

Abstract: Lung volume reduction surgery (LVRS) improves the fit of severely hyperinflated emphysematous lungs to the surrounding chest cavity and thereby improves respiratory mechanics and expiratory airflow. LVRS is a potent and life extending therapy for some patients with severe emphysema and has a low associated operative mortality. The national emphysema treatment trial (NETT) identified characteristics of patients for whom LVRS improves survival, function and health-related quality of life and characteristics of patients who should not have surgery. Patients with upper-lobe predominant distribution of emphysema on high-resolution computed tomogram are most likely to benefit from LVRS vs. optimal medical therapy and rehabilitation. At long-term follow-up, the survival and functional benefits derived from LVRS are durable. In efforts to make lung volume reduction safer and more broadly accessible physician-scientists have developed bronchoscopic lung volume reduction (BLVR) procedures. Early clinical trials of BLVR performed with endobronchial valves (EVB) and sclerosant biogels demonstrate their safety. The ability of BLVR EBV techniques to produce desired atelectasis and lung volume loss is likely limited in those patients with collateral ventilation, incomplete fissures and those unable to achieve complete lobar exclusion. Results from a phase III BLVR EBV trial are in analysis. [Copyright &y& Elsevier]

Abstract: Background: Surgical resection remains the most effective therapy for metastatic colorectal cancer confined to the liver, although the extrahepatic recurrence rate is high. Aim of the study: To develop a mammal model in order to investigate by which mechanisms liver surgery affects distant tumour recurrence. Methods: In this animal study the effect of partial hepatectomy (phX) on the development of tumour noduli in the lungs was evaluated. CC531 rat colon carcinoma cells were inoculated i.v. 24h before, during or 24h after surgery. Rat serum was obtained at different time-points after phX and added to in vitro CC531 cell cultures. Finally, phX was compared with an ileum resection (ilX). Results: phX leads to increased tumour noduli in the lungs, compared to Sham operation (p =0.002), but only when performed directly before the injection of tumour cells and not when performed 24h before or after the inoculation. Comparable results were obtained for ilX. No growth stimulation of tumour cells after incubation with rat serum, obtained at different time-points after phX, could be detected in vitro. Conclusion: Not only phX, but also surgery, in general promotes distant tumour recurrence exerting the effect during the early phase of tumour cell adhesion and not during tumour outgrowth. [Copyright &y& Elsevier]

Spontaneous pneumothorax is usually caused by the rupture of subpleural blebs/bullae in the underlying lung and is one of the most common elective applications of video-assisted thoracoscopic surgery (VATS). VATS has been used as an alternative to thoracotomy in the treatment of spontaneous pneumothorax. Recurrent pneumothorax and persistent air leakage are quite often indications for spontaneous pneumothorax, and bilateral spontaneous pneumothorax is also considered to be an indication for surgical intervention. The goals of surgical intervention are to eliminate intrapleural air collection and prevent recurrence. Diverse procedures have been reported in the surgical treatment for spontaneous pneumothorax. We review the literature regarding the VATS approach for spontaneous pneumothorax. [ABSTRACT FROM AUTHOR]

After announcements of successful hand, larynx, knee, muscle, nerve, and, most recently, face transplantation, composite tissue allografts (CTAs) have been introduced into the armamentarium of plastic and reconstructive surgery. Because the microsurgical techniques required to perform CTA transplants are well established and used in daily practice by plastic surgeons, the immunologic aspects of transplantation remain of great interest to plastic surgeons. CTAs offer a unique potential for coverage of large multitissue defects; however, compared with the relatively homogenous tissue of solid organ transplants, the heterogenicity of tissue components of CTA may generate high immunologic responses. Although modern immunosuppressive agents significantly improve successful allograft acceptance, chronic allograft rejection as well as immunosuppressive drug toxicity remain major problems in the clinical practice of transplantation. The major goal of transplantation immunology is to develop tolerance to allograft transplants and long-term drug-free survival. Several experimental protocols have been designed to develop tolerance; however, none of them have been proved to induce tolerance in clinical transplantation. This review outlines the mechanisms of allograft acceptance and rejection and describes the barriers to transplantation tolerance based on our current knowledge as it applies to solid organs and CTA transplants. The review also describes innovative immunosuppressive protocols. [ABSTRACT FROM AUTHOR]

Thoracoscopic esophageal surgery is a complex procedure requiring simultaneous dissection of the esophagus and lymph nodes while maintaining the surrounding vessels. Because of the difficulty in obtaining comprehensive views of the operative field, three-dimensional (3-D) images with preoperative information on the vascular system, esophagus, trachea, lungs, lymph nodes, skin, and bones would be extremely helpful in performing the surgery. [ABSTRACT FROM AUTHOR]

Abstract: Background and purpose: To evaluate the feasibility of sparing the parotid glands and surgically transferred submandibular gland (SMG) by intensity modulated radiotherapy (IMRT) in post-operative cases of head and neck cancer (HNC). Materials and methods: Ten patients (larynx-2, base of tongue-4, tonsil-3, and unknown primary-1; pathologic stages III–IV) who underwent SMG transfers on the side of N0 neck along with definitive surgery were selected for this study. IMRT planning was done retrospectively using helical tomotherapy approach. Planning objective was to deliver 60Gy to PTV1 and 54Gy to PTV2 while maintaining the mean dose to the total parotid volume (TPV) and SMG less than 26Gy. Results: The mean dose (±SD) to the TPV and SMG were 25±0.6Gy and 23±1.9Gy, respectively. The D 95 for PTV1 and PTV2 were 59.9±0.1Gy and 54.9±0.3Gy, respectively, satisfying our planning goal for PTV coverage. The D 99 for PTV1 and PTV2 were 58.2±0.7Gy and 49.5±2.2Gy, respectively, showing that sparing the salivary glands did not result in underdosing of the PTVs. Conclusions: By combining the gland transfer and IMRT, the mean dose to TPV and transferred SMG could be reduced to less than 26Gy in post-operative patients of HNC. [Copyright &y& Elsevier]

Introduction: Adenotonsillectomy is successful at eliminating airway obstruction in the majority of otherwise normal children with obstructive sleep apnoea syndrome. Children with this condition are at significantly higher risk of post-operative respiratory complications. Identifying children at risk of post-operative respiratory complications after adenotonsillectomy for obstructive sleep apnoea syndrome remains a challenge for clinicians, especially those at district general hospitals.Aim: To review the evidence and to proffer a pragmatic approach to diagnosis and management, by classifying those at risk of post-operative respiratory complications into different risk subsets, with guidelines for management.Conclusion: Patients in the high risk group should be operated upon at paediatric specialist centres with intensive care facilities. Those in the moderate risk group may undergo adenotonsillectomy at their district general hospital, provided facilities for administering continuous positive airway pressure are available on-site. Most children with obstructive sleep apnoea syndrome may be classified as low risk candidates and may safely be operated upon at their local district general hospital. [ABSTRACT FROM AUTHOR]

The article discusses a review comparing recurrence rates from video-assisted surgery of recurrent pneumothorax against open surgery through analysis of randomized studies. Results of video-assisted and open pneumothorax surgery were combined in a meta-analysis with fixed and random effects models applied. The analysis revealed that the relative risk of recurrence is four times greater when pleurodesis surgery is performed using video-assistance.

Purpose: We investigated how the preoperatively estimated integrity of pelvic floor muscles related to the recovery of continence after radical prostatectomy. Materials and Methods: A total of 94 patients underwent magnetic resonance image of the prostate and urodynamic studies before undergoing radical prostatectomy and evaluation of voiding symptoms before, and 3 and 6 months after surgery. Incontinence was defined as any unwanted urine leakage. On the magnetic resonance image the thickness of the levator ani and pelvic diaphragm, and prostate volume were measured to correlate with continence status. Results: Incontinence was noted in 41.5% and 15.9% of the patients at 3 and 6 months, respectively. Recovery of continence 3 months after RP was related to the thickness of the pelvic diaphragm on sagittal imaging (p = 0.017), the ratio of the levator ani on the axial image to prostate volume (p = 0.047), functional urethral length (p = 0.007) and incontinence before surgery (p = 0.009). Recovery at 6 months was related to neurovascular bundle sparing (p = 0.013) and marginally to the pelvic diaphragm on sagittal imaging (p = 0.059). On multivariate analysis the pelvic diaphragm on sagittal imaging (HR 2.455, 95% CI 0.894–6.739, p = 0.008) and the ratio of the levator ani on the axial image to prostate volume (HR 1.886, 95% CI 0.952–3.736, p = 0.011) significantly predicted continence at 3 months, while at 6 months only the pelvic diaphragm on sagittal imaging showed a significant relationship (p = 0.024). Conclusions: Pelvic diaphragm thickness and the ratio of levator ani thickness to prostate volume are independent factors predictive of post-prostatectomy incontinence. Patients with better developed pelvic floor muscles, especially in relation to the size of the prostate, can be expected to achieve earlier recovery of continence after radical prostatectomy. [Copyright &y& Elsevier]

Background: Whether and how mitral regurgitation impacts perioperative outcome of noncardiac surgery remains unclear. Methods: From November 1999 to August 2004, all patients undergoing noncardiac operations and ever examined by echocardiography within prior 12 months were screened. Those with moderate-severe or severe mitral regurgitation were enrolled provided they were not already trachea-intubated and the surgery was not performed under local anesthesia. The perioperative outcomes of these patients were analyzed, and related prognostic predictors were investigated by multivariate logistic regression analysis. Results: A total of 84 patients (43 men, mean age of 66 years, low surgical risk in 28 and intermediate in 56) complying with the inclusion criteria were included. Their surgery was complicated by frequent (31%) yet minor intraoperative adverse events of controllable hypotension and bradycardia. In contrast, the postoperative outcomes were seriously complicated with high morbidity (27.4%, mostly pulmonary edema and prolonged tracheal intubation) and mortality (11.9%). Atrial fibrillation was identified by multivariate logistic regression analysis as the predictor of inhospital death (OD 11.579, P = .003), whereas surgical risk level (OD 5.118, P = .021), left ventricular ejection fraction (OD 0.958, P = .026), and atrial fibrillation (OD 3.058, P = .045), as independent predictors of postoperative morbidity. Conclusions: Under current anesthetic management, patients with advanced mitral regurgitation could go through fairly safe intraoperative course of noncardiac surgery despite minor complications. Their postoperative outcome was, however, complicated by extraordinarily high morbidity and mortality, especially in those with preexisting atrial fibrillation, higher surgical risk level, and lower left ventricular ejection fraction. [Copyright &y& Elsevier]

Abstract: We report a giant hemangioma that extended from the mesopharynx to the larynx in an adult. The patient was a 39-year-old woman who had demonstrated an asymptomatic pharyngeal hemangioma since she was 1 year-old. She developed vertigo and consulted a hospital at the age of 39. During screening by head MRI for the diagnosis of the vertigo, hemangioma of the laryngopharynx was detected. She was referred to Osaka National Hospital for further examination. Her subjective symptoms were dyspnoea in the lower left lateral-position. On observation by nasopharyngolaryngovideoscope, a giant hemangioma was diagnosed in the left mesopharynx expanding into the larynx. On MRI study, hemangioma widely extended to the right posterior wall at the mesopharynx level. Since we were concerned about risk of choking if the hemangioma of the larynx were left untreated, we recommended surgery. Under the general anesthesia, hemangioma of the larynx was light-coagulated by KTP laser through tracheotomy. The postoperative-course has been good and at 9 months postoperatively, there was no progression of hemangioma. [Copyright &y& Elsevier]

The functional results of a partial laryngeal surgery or a laryngeal reinnervation depend on the precise knowledge of the intra laryngeal anatomy of the inferior laryngeal nerve (ILN). Ten human larynges without known laryngeal disorders were obtained from human cadavers for ILN microdissection. Intra laryngeal ILN branching patterns were determined bilaterally. The lengths of the vertical, genu and oblique segments of the anterior division of ILN and the distance between the nerve within the paraglottic space and the cricothyroid articulation (CTA) were measured with a digital microcaliper. The mean lengths of the vertical, genu and oblique segments were 10.82, 5.89 and 9.29 mm, respectively. The mean distance between the nerve in the paraglottic space and the CTA was 11.20 mm. Key anatomical landmarks of the abductor division (vertical and genu segments of ILN) were the lateral border of posterior cricoarytenoid (PCA) muscle and the superior ligament of the CTA. The two-branch pattern for the lateral border of the PCA muscle has been the most frequent (50%). A branch of interarytenoid muscle (IA) originated from the genu segment. One or two branches for the PCA muscle has been identified in 75% of cases from the IA neural plexus on the front side of PCA muscle. The adductor division for the thyroarytenoid muscle and the lateral cricoarytenoid muscle was the oblique segment of the nerve. We conclude that abductor and adductor divisions of intra laryngeal ILN can be readily identified and the knowledge of key landmarks allows preservation of the ILN during partial surgery of the larynx and possibly selective muscle reinnervation. [ABSTRACT FROM AUTHOR]

Background. Controversy surrounds the safety and practicality of the retrograde percutaneous translaryngeal tracheostomy (Fantoni procedure) compared with other percutaneous methods. Methods. We used the Fantoni tracheostomy for 245 patients in our intensive care unit (ICU) over a period of 3 years 6 months and conducted a prospective analysis. Results. We are able to report a low incidence of complications (1.2%) with the Fantoni procedure. Advantages of the method are reduced tissue trauma and optimal adaptation of the stoma to the cannula, leading to less stomal bleeding and fewer infectious complications. We observed no procedure-related mortality. Under mandatory bronchoscopic control, proper puncture location and cannula placement are ensured, which prevents tracheal wall injury and paratracheal placement of the cannula. Conclusions. Our experience shows that the major advantage of the use of the Fantoni tracheostomy is the retrograde dilatation of the stoma, which prevents serious complications compared with other techniques. © 2005 Wiley Periodicals, Inc. Head Neck28: 355–359, 2006 [ABSTRACT FROM AUTHOR]

Objectives: After a first clinical study showing a high prevalence of gastrointestinal tract diseases in brachycephalic dogs presented for upper respiratory syndrome, a prospective study was performed to determine the influence of medical treatment for gastrointestinal tract disorders associated with upper respiratory syndrome surgery. Methods: The gastrointestinal tract and respiratory disorders of 61 brachycephalic dogs presented for upper respiratory syndrome were evaluated. Together with surgery of the upper respiratory tract, a specific gastrointestinal medical treatment was administered. A minimal follow-up of six months was required for inclusion. Results: Palatoplasty with rhinoplasty was the most common surgical correction (88·5 per cent). The mortality rate in the perioperative period was 3·3 per cent. Minor complications accounted for 26·2 per cent of cases. No aspiration pneumonia was encountered. A sufficient follow-up was obtained in 51 dogs. The improvement was judged by the owners as excellent or good in 88·3 per cent of the respiratory disorders and in 91·4 per cent of the gastrointestinal disorders. Clinically, a statistically significant improvement was obtained for both respiratory and gastrointestinal disorders. Clinical Significance: In comparison with other studies, digestive tract medical treatment combined with upper respiratory surgery seems to decrease the complication rate and improve the prognosis of dogs presented for upper respiratory syndrome. [ABSTRACT FROM AUTHOR]

Total laryngectomy results in a permanent disconnection of the upper and lower airways and inevitably leads to chronic pulmonary complaints like frequent involuntary coughing, increased sputum production and repeated daily forced expectoration to clean the airway. Heat and moisture exchangers (HMEs), applied in an attempt to compensate for the lost functions of the upper respiratory tract, have been found to diminish these symptoms and improve the quality of life significantly. An HME has three physical properties that might be responsible for these improvements. First, its heat and moisture exchanging capacity improves intra-airway preservation of heat and water. Since the condensation and evaporation of moisture are accompanied by the release and uptake of thermal energy, these parameters are inseparable. Secondly, the HME’s resistance may reduce dynamic airway compression, thereby improving ventilation. Thirdly, to some extent, an HME might filter out particles, thereby cleaning inspiratory breathing air. This article summarizes our present knowledge of changes in respiratory physiology after total laryngectomy and the influence of the HME by reviewing the physiological impact of these three physical properties separately for in vitro and in vivo data. [ABSTRACT FROM AUTHOR]

Dorsal stabilization techniques based on the fixateur interne principle are regarded as the primary treatment method for unstable spinal injuries. For certain types of fracture associated with extensive destruction or defects of the vertebral body and the intervertebral discs, reconstruction of the load-bearing anterior spine is required to avoid loss of correction. Further development of endoscopic technique and standardization of the operating procedure have now made it possible to perform the operation on the ventral section of the spine using minimally invasive thoracoscopy. The operation involves removal of the ruptured intervertebral discs and vertebral fragments including, when necessary, decompression of the spinal canal. The load-bearing capacity of the anterior spine is restored using a vertebral body replacement and ventral instrumentation. The extended thoracoscopic approach described here also opens the retroperitoneal segment between Th12 and L3 to the endoscopic procedure via partial detachment of the diaphragm. Thus, it includes the thoracolumbar section of the lumbar spine, which is the area most frequently affected by fractures. [Copyright &y& Elsevier]

Complications at extubation remain an important risk factor in anaesthesia. A postal survey was conducted on extubation practice amongst consultant anaesthetists in the United Kingdom and Ireland. The use of short acting drugs encourages anaesthetists to extubate the trachea at lighter levels of anaesthesia. The results show that oxygen (100%) is not routinely administered either before extubation or en route to the recovery area. A trend towards a head up or sitting position at extubation is emerging. However, further research into the use of these positions is required. Airway related complications at extubation are relatively frequent but are usually dealt with by simple basic measures. The role of drugs such as propofol in decreasing the incidence of these complications needs further evaluation. Some of these results give concern for patient safety and for training. The importance of teaching and adherence to continued oxygenation until complete recovery is strongly emphasised. Nerve stimulators should be used continually as standard monitoring throughout the anaesthetic period when muscle-relaxing drugs are part of the anaesthetic technique. [ABSTRACT FROM AUTHOR]

This article focuses on a study related to reviewing of coronary artery disease (CAD) prevalence among lung transplantation (LTx) candidates, the time interval from coronary angiography (CA) to LTxldeath, and postrevas-cularization outcomes. LTx has emerged as a successful therapeutic modality for end-stage pulmonary disease in recent years. Because of the scarcity of donor lungs, patients referred for LTx are carefully screened for concomitant medical problems that might compromise their success of the transplant surgery or limit their survival after surgery.

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OBJECTIVES/HYPOTHESIS: The objective was to compare the laryngeal mask airway and endotracheal tube for airway protection from blood during sinonasal surgery. STUDY DESIGN: Nonrandomized, controlled, prospective clinical trial. METHODS: Patients scheduled to undergo sinonasal surgery (septoplasty and/or endoscopic sinus surgery) were prospectively enrolled and grouped according to type of airway during general anesthesia with choice of airway device based on the anesthesiologist'''s preference. Clinical data were tabulated by case including airway device, patient age, weight, estimated blood loss, airway pop-off pressure, and emergence quality. At the conclusion of surgery, the airway was examined through the laryngeal mask airway or endotracheal tube with a flexible fiberoptic bronchoscope to determine the amount of blood present on the vocal cords or in the trachea. The airway device was also evaluated postoperatively for the presence of blood. RESULTS: Seventy-six adult patients were initially enrolled; two were excluded because fiberoptic evaluation of the airway could not be completed. Of the remaining 74 patients, an endotracheal tube and laryngeal mask airway were used in 31 and 43 patients, respectively. The two groups did not differ with respect to age, weight, estimated blood loss during surgery, pop-off pressure, or emergence quality (all P > .05). Patients managed with an laryngeal mask airway were significantly less likely to have blood staining the airway (glottis or trachea) than patients with an endotracheal tube (19.5% vs. 84.8%, '' test [P < .001]). However, the endotracheal tube provided better protection than the laryngeal mask airway against distal tracheal blood contamination (3.2% vs. 14.6%, respectively [P = .110]). CONCLUSION: The laryngeal mask airway provides better protection of the upper airway from blood contamination during sinonasal surgery than a standard endotracheal tube, but there is a higher incidence of distal tracheal contamination. The laryngeal mask airway is a reasonable alternative to endotracheal intubation for airway management in sinonasal surgery. [ABSTRACT FROM AUTHOR]

Study objectives: The role of open-lung biopsy in ARDS has been questioned due to potentially high morbidity and low diagnostic yield. The goals of this study were to better define the frequency of unexpected diagnoses made by open-lung biopsy, the frequency biopsy results lead to a change in clinical management, and the frequency of procedural complications. Design: Case series. Setting: A large tertiary referral center. Patients: All individuals with available records undergoing open-lung biopsy between 1989 and 2000 for evaluation of ARDS based on the American-European Consensus Conference definition. Interventions: None. Measurements and results: The mean age in this cohort of 57 patients was 53 years (SD, 18 years) with Pa[sub O[sub 2]]/fraction of inspired oxygen ratio of 145 mm Hg (SD, 61 mm Hg) at the time of biopsy. A pathologic diagnosis other than diffuse alveolar damage or fibroproliferation was found in 60% of patients. The most common alternative diagnoses were infection (n = 8), alveolar hemorrhage (n = 5), and bronchiolitis obliterans organizing pneumonia (n = 5). Alternative diagnoses were as frequent in immunocompetent as immunosuppressed hosts (60% vs 59%, respectively). Biopsy results led to a change in management in the majority of patients, with addition of specific therapy in 60% and withdrawal of unneeded therapy in 37%. Although the overall complication rate was 39%, major complications occurred in only 7% of cases. No deaths were attributable to the procedure. Conclusions: In selected patients with clinical ARDS, open-lung biopsy can be performed safely, often reveals an unsuspected diagnosis, and frequently leads to alterations in therapy. Key words: ARDS; open-lung biopsy; pulmonary surgical procedures. [ABSTRACT FROM AUTHOR]

Objective: To develop and evaluate a postprocessing tool to quantify ventilated split-lung volumes on the basis of ³He-MRI and to apply it in patients after single-lung transplantation (SLTX). High-resolution CT (HRCT) was employed as a reference modality providing split air-filled lung volumes. Lung volumes derived from pulmonary function test results served as clinical parameters and were used as the "gold standard." Material and methods: Eight patients (mean age, 54 years) with emphysema and six patients (mean age, 58 years) with idiopathic pulmonary fibrosis. All patients were evaluated following SLTX. HRCT was performed during inspiration (slice thickness, 1 mm; increment, 10 mm). For correlation with ³He-MRI, HRCT images were reconstructed in coronal orientation to match the same anatomic levels. Aerated lung was determined by threshold-based segmentation of CT. ³He-MRI was performed on a 1.5-T scanner using a two-dimensional, fast low-angle shot sequence in coronal orientation covering the whole lung after inhalation of a 300-mL bolus of hyperpolarized are gas followed by normal room air for the rest of the tidal volume. Lung segmentation on ³He-MRI was done using different thresholds. Results: In emphysematous patients, ³He-MRI showed excellent correlation (r = 0.9) with vital capacity, while CT correlated (r = 0.8) with total lung capacity, ³He-MRI correlated well with CT (r > 0.8) for grafts and native fibrotic lungs. In emphysematous lungs, MRI showed a good correlation (r = 0.7) with the nonemphysematous lung volume from CT. Increasing thresholds in ³He-MRI reveal differences between aerated and ventilated lung areas with a different distribution in emphysema and fibrosis. Conclusions: ³He-MRI is superior to CT in emphysema to demonstrate ventilated lung areas that participate in gas exchange. In fibrosis, ³He-MRI and CT have a similar impact. The decrease pattern and the intraindividual ratio between ventilation of native and transplanted lungs will have to be investigated as a new surrogate for the ventilatory follow-up in patients undergoing SLTX. Key words: CT; hyperpolarized ³He; MRI; single-lung transplantation; split-lung function. [ABSTRACT FROM AUTHOR]

Study objectives: To review our experience with specific characteristics, indications, and results of pulmonary resection in children with middle lobe/lingula syndrome. Design: Retrospective cohort study. Setting: Thoracic Surgery Department, Chest Diseases Hospital, Kuwait. Patients and intervention: Thirteen children with middle lobe, lingula, or both syndromes were treated with pulmonary resection from January 1995 to December 1999. Results: The mean age was 7.5 years (range, 5 to 10 years). Eight patients were girls, and five were boys. All patients underwent high-resolution CT and bronchoscopy. Bronchiectasis and atelectasis of right middle lobe, lingula, or both was noted in nine patients. Bronchial stenosis and inflammation of the bronchus was found endoscopically in four patients. The indications for surgery were recurrent respiratory tract infection with persistent atelectasis and bronchiectasis in nine patients, and recurrent respiratory tract infection with bronchiectasis in four patients. A right middle lobectomy was done on seven patients and a lingulectomy on four patients. Two patients underwent staged thoracotomies (right middle lobectomy and lingulectomy). There were no operative deaths. Only two patients had postoperative complications: atelectasis (n = 1), and pneumothorax (n = 1). Mean follow-up was 3.5 years (range, 3 to 5 years) for all patients. Nine patients were asymptomatic, and four patients had improved. Conclusion: Right middle lobe or lingula syndrome with the presence of bronchiectasis, bronchial stenosis, or failure of lung to re-expand are indications for early pulmonary resection. Key words: atelectasis; bronchiectasis; pulmonary resection; right middle lobe. [ABSTRACT FROM AUTHOR]

Study objectives: To evaluate the safety and efficacy of additional minocycline pleurodesis after thoracoscopic treatment of primary spontaneous pneumothorax. Design: Retrospective comparative study with a historical control. Setting: Thoracic surgical division of a university-affiliated tertiary medical center. Patients and methods: Between April 1994 and April 2001, 313 consecutive patients (minocycline group) with primary spontaneous pneumothorax were treated by video-assisted thoracoscopic surgery. The procedures included resection of the blebs and mechanical pleurodesis by scrubbing the parietal pleura. After operation, minocycline hydrochloride, 7 mg/kg, was instilled into the pleural space through a thoracostomy tube. The control group consisted of 51 consecutive patients who underwent the same thoracoscopic procedures alone for primary spontaneous pneumothorax between January 1992 and April 1994. Results: There was no significant difference between the two groups in terms of demographic data, operative findings, and operation time. Chest pain was a common complaint after minocycline pleurodesis, but the total doses of requested analgesics were comparable in both groups. The rate of prolonged air leaks was significantly lower in the minocycline group (7.0% vs 17.6%, p = 0.025). Patients treated with minocycline had shorter periods of postoperative chest drainage and hospitalization. The ipsilateral recurrence rate was also significantly lower in these patients (2.9% vs 9.8%, p = 0.033). Conclusions: Minocycline pleurodesis is a safe and convenient procedure that may improve the outcome and reduce the rate of recurrence after thoracoscopic treatment for primary spontaneous pneumothorax. A randomized control study may be needed to confirm the findings. Key words: minocycline; pleurodesis; primary spontaneous pneumothorax; thoracoscopy. [ABSTRACT FROM AUTHOR]

To report the functional and oncologic results of larynx preservation surgery with free flap reconstruction for posterior pharyngeal wall carcinoma. Retrospective medical chart review. Tertiary care referral center. We present a series of seven patients, who were treated for an advanced stage posterior pharyngeal wall carcinoma between 1995 and 1998. All patients underwent posterior pharyngectomy with larynx preservation via a suprahyoidal approach for carcinoma of the posterior pharyngeal wall, with radial forearm free flap reconstruction. Complications occurred in three patients with grade 3 comorbidity, one of whom suffered flap loss. After a mean follow-up of 48 months, three patients are alive without disease. One patient is alive with a second primary tongue carcinoma. Two patients died of disease, whereas one patient died of another cause. All patients could be decannulated and maintain their voice. Six out of seven patients were able to take oral nutrition, although four patients needed additional PEG-tube feeding. Posterior pharyngectomy with larynx preservation and radial forearm free flap reconstruction is feasible in selected patients, with acceptable functional results and survival. However, the patient must be aware of the risk of chronic aspiration and the possibility of long-term PEG feedings. [Copyright &y& Elsevier]

The clinical application of the current methods of measuring nasal obstruction has been limited by complicated, invasive and stressful procedures that require the full co-operation of the patient. A pilot study is described where a simple way of evaluating nasal obstruction, based on oscillation methods, was investigated. The technique did not disturb spontaneous breathing and required little co-operation and comprehension. Significant differences were obtained when clinically classified normal (5.2 +/- 1.8 cmH2O l(-1) s) and patient (10.6 +/- 5.9 cmH2O l(-1) s) groups were evaluated (p<0.01). A significant reduction (p<0.02) was also observed in impedance results before (8.5 +/- 1.1 cmH2O l(-1) s) and after (5.2 +/- 1.7 cmH2O l(-1) s) clinically successful nasal surgery, closely reflecting the clinical conditions of the subjects. This simple forced oscillation technique showed good potential for future clinical applications in the pre-screening of nasal patients and the evaluation of therapeutic surgery. [ABSTRACT FROM AUTHOR]

We subjectively and objectively evaluated 136 patients with socially unacceptable snoring (SUS) or obstructive sleep apnoea syndrome (OSAS) treated with uvulopalatopharyngoplasty (UPPP) after a diagnostic workup by sleep registration (polysomnography, PSG) and sleep endoscopy. Of the 136 patients, there were 88 with OSAS and 48 with SUS. The results of the procedure were considered subjectively to be an improvement in 38 (79%) of the SUS patients and in 74 (84%) of the patients with OSAS. In 36 (40%) of the 88 patients with OSAS, repeating PSG postoperatively was considered unnecessary because of obvious improvement. Of the 52 patients with a measurement after UPPP, a decrease in the apnoea hypopnoea index (AHI) was found in 38 (73%; median decrease: 48%), and AHI dropped below 20 in 32 (62%). The apnoea index (AI) was available in 49 (56%) patients and was reduced in 31 (63%; median decrease: 73%). An overall positive result in the 88 patients with OSAS (combining available data on subjective and objective results) was therefore found in 61 (69%; positive subjective result and AHI <15) or 71 (81%; positive subjective result and decrease in AHI), respectively, depending on the definition. We conclude that after diagnostic workup by sleep registration and sleep endoscopy, the success rate of UPPP increases as compared to historical controls. [ABSTRACT FROM AUTHOR]

Objective: To review our experience with bilateral video-assisted thoracoscopic surgery (VATS) for the treatment of bilateral spontaneous pneumothorax (SP).Design: Retrospective study followed by a telephone interview for follow-up.Setting: Thoracic Surgery Department, Chest Diseases Hospital, Kuwait.Patients and Interventions: Fifteen patients undergoing bilateral VATS for bilateral SP from 1994 to 1999.Results: The mean age of the patients was 22.9 years (range, 17 to 34 years), and 14 were men. All patients were successfully treated using the bilateral video-assisted technique. Operative indications included simultaneous bilateral pneumothorax (n = 7) and contralateral recurrence of SP (n = 8). Twelve patients had primary SP. In the three remaining patients, simultaneous bilateral SP was secondary to sarcoidosis in two patients and histiocytosis X in one patient. Eleven patients had multiple blebs or bullae located in the upper lobes, and 4 patients had no blebs. All blebs or bullae were resected. All patients had gauze pleurodesis. The mean +/- SD operative time was 133.6 +/- 9.1 min. There were no perioperative complications and no deaths attributable to the procedure. Postoperative prolonged air leak occurred in three patients (20%). The mean drainage time was 3 days (range, 2 to 8 days). The mean postoperative hospital stay was 5 +/- 1.7 days. Mean follow-up was 3.3 years (range, 2 to 5 years) for all patients. Pneumothorax recurred in one patient with histiocytosis X after 1 month and required a reoperation on the right side.Conclusions: Bilateral VATS is a safe procedure in the treatment of simultaneous and nonsimultaneous bilateral SP. This avoids the need for subsequent operations. [ABSTRACT FROM AUTHOR]

The article offers information on the advanced upper airway obstruction in ear, nose and throat (ENT) surgery. It states that defining the extent level of the obstruction is mandatory before surgery which includes fibre-optic nasendoscopy and computed tomography (CT) scan. Procedure in operating includes rehearsing a fall-back position in the operating theatre with a senior ENT surgeon scrubbed, and tracheostomy should be set opened and a rigid bronchoscope at hand.

Background: A study was undertaken to evaluate whether adults differ from children in the indications and outcome of diaphragmatic plication following phrenic nerve injury. Methods: A retrospective study was performed of 21 patients, 10 below the age of 5 and 11 older than 37 years. The indication for surgery for all the children was failure to wean from ventilatory support. The indications for surgery in the adult group were ventilator dependency (n=4) and symptomatic dyspnoea (n=7). All patients had at Least one imaging study confirming diaphragmatic paralysis. The American Thoracic Society (ATS) dyspnoea scale, pulmonary function tests, and quantitative pulmonary perfusion scans were used as evaluation parameters. At surgery the diaphragm was centrally plicated. Results: One child died immediately after surgery due to irreversible heart failure and two children died within 2 months of surgery from ongoing complications of their original condition. These three patients were considered as selection failures. Seven children were weaned from ventilatory support within a median of 4 days (range 2-140). Only one of four ventilated adults was successfully weaned. Seven adults who underwent surgery for chronic symptoms had a marked subjective improvement of 2-3 levels in the ATS dyspnoea scale. Pulmonary function studies in the seven symptomatic adults showed a 40% improvement above baseline. Severely asymmetrical perfusion scans reverted to a normal pattern after plication. Conclusions: Diaphragmatic plication offers a significant benefit to children with diaphragmatic paralysis and should be performed early to facilitate weaning from mechanical ventilation. While plication is of limited benefit in weaning ventilated adults, it results in significant subjective and objective lifetime improvement in non-ventilated symptomatic adults. [ABSTRACT FROM AUTHOR]

Objective: To compare two ventilator settings in the postoperative weaning period. Patient-triggered automatic switching between controlled ventilation and supported spontaneous breathing (Automode, AM) was compared to synchronised intermittent mandatory ventilation (SIMV) with stepwise manual adjustment of mandatory frequency according to the breathing activity.Design: Prospective clinical investigation.Setting: Eighteen-bed intensive care unit in a university hospital.Patients: Forty postoperative patients with healthy lungs who had undergone brain tumour surgery.Interventions: Randomisation either to the AM or SIMV weaning procedure after entering the ICU.Measurements and Results: Total weaning time and number of manipulations on the ventilator were observed. Cardiocirculatory and respiratory parameters were measured consecutively at five points during the weaning period. No significant differences were seen for cardiocirculatory parameters, airway pressures and oxygenation between the two groups. There was a trend to shorter weaning times with AM (136 +/- 46 min vs 169 +/- 68 min, n.s.), the average number of manipulations on the ventilator was lower (0.55 +/- 0.69 vs 5.05 +/- 1.19,p < 0.001) and arterial partial pressure of carbon dioxide (PaCO2) levels showed fewer variations in the late phase of the weaning period (39.5 +/- 3.1 vs 38.3 +/- 7.2, p < 0.001 for differences in variance).Conclusions: Automatic, patient-triggered switching between controlled and supported mode of ventilation can be used for postoperative weaning of neurosurgical patients with healthy lungs. Compared to a SIMV weaning procedure, fewer manipulations on the ventilator are necessary and individual adaptation of ventilation seems to be more accurate. [ABSTRACT FROM AUTHOR]