Search

Objective: We aimed to examine the demographic characteristics, etiology and postoperative mortality rates of neonates operated on in our hospital. Methods: The records of neonates who were operated in our tertiary care level university hospital between 2013 and 2019 were reviewed retrospectively. Patients with a diagnosis requiring surgical procedure, age (days), gender, anatomical region where the surgical procedure was performed, length of hospital stay, and mortality rates were investigated. Results: 329 neonates were included in the study of which 213 (64.75%) were male and 116 (35.25%) were female. Gastrointestinal system surgery was performed in 214 patients (65.04%), respiratory system surgery in 95 (28.87%) patients and urogenital system surgery in 17 (5.16%) patients. The mortality rate of 156 patients that were followed up in our neonatal unit in the postoperative period was 16.6%. The mortality rate of female babies (21.3%) was higher than that of male babies (13%). Considering the mortality rates of the patients according to the surgical areas, the highest mortality rate was found in respiratory system surgery (38.46%) which was trailed by gastrointestinal system surgery (12.28%) and urogenital system surgery (7.69%), respectively. Conclusions: Despite advances in neonatal care and surgical techniques, immaturity and congenital anomalies still have an important place among the most common causes of death in infants. In particular, the detection of organ dysfunctions due to congenital anomalies which are considered among the preventable causes of death in infants, efforts to correct them will be beneficial to a certain extent in reducing the mortality rates of neonates. [ABSTRACT FROM AUTHOR]

Introduction The immune reaction developing against Ebstein-Barr virus (EBV) infection may be one of the major determinants of severe adenoid hypertrophy (AH) and chronic otitis media with effusion (COME) needing surgery. In this study, we aimed to investigate the relationship between these antibodies and the need for surgery due to complications such as severe AH and COME. Methods Sixty consecutive patients <15 years old who were admitted to our outpatient clinics between January 2014 and December 2015 with severe AH ± COME and underwent adenoidectomy ± ventilation tube insertion and 129 control patients who had a history of EBV infection at least three months before the inclusion to the study without current symptoms of upper airway obstruction and middle ear disease were included in this study. Two groups of patients and a control group were studied: a) children who underwent adenoidectomy alone with no middle ear disease (group 1), b) children with COME and AH who underwent adenoidectomy and tympanostomy with ventilation tube insertion (group 2), and c) control group without adenoid hypertrophy or otitis media with effusion. Results Patients who needed surgery (Group 1 and 2) had significantly higher levels of anti-EBV VCA IgG antibodies than control patients (19.8 ± 16.4 vs. 1.7 ± 0.8 S/CO, p < 0.001). Anti-EBV VCA IgM levels did not differ between groups. Group 2 patients had also higher levels of Anti-EBV VCA IgG antibodies than group 1 patients (35.8 ± 16.7 vs. 11.8 ± 8.5 S/CO, p < 0.001). ROC curve analysis resulted in a cut-off point of 2.92 S/CO level for anti-EBV VCA IgG antibodies for need for surgery in EBV infected patients with 97% sensitivity and 98% specificity. Conclusion Markedly increased serum anti-EBV VCA IgG antibodies in children who developed upper respiratory tract complications such as severe AH and COME may show the significant role of enhanced immune system reaction in the pathogenesis of these complications due to EBV infection. [ABSTRACT FROM AUTHOR]

Background: Treatment of congenital pulmonary airway malformations (CPAMs) is generally surgical resection; however, there is controversy regarding the optimal timing of surgical intervention, especially in asymptomatic patients.Study Design: Using the American College of Surgeons National Surgical Quality Improvement Program-Pediatric Participant Use Files from 2012 to 2015, children who underwent lung resection for CPAMs were identified. Outcomes in children who underwent lung resection during the neonatal period were compared with those who underwent resection beyond the neonatal period, but during the first year of life (non-neonates).Results: A total of 541 patients (20.7% neonates and 79.3% non-neonates) were identified. Neonates had higher rates of preoperative comorbidities and worse postoperative outcomes when compared with non-neonates (morbidity 19.6% vs 5.4%, p < 0.0001). On multivariable regression analysis, the presence of preoperative symptoms (defined as oxygen dependence or ventilatory support) was independently associated with increased morbidity (odds ratio 3.91 [range 1.6 to 9.57], p = 0.003). In a subgroup analysis of asymptomatic neonates compared with asymptomatic non-neonates, there was no difference in overall morbidity (7.4% vs 4.4%, p = 0.33).Conclusions: These data suggest that lung resection for CPAMs in the neonatal period in asymptomatic children are not associated with increased 30-day morbidity. The presence of preoperative symptoms was independently associated with increased morbidity in a multivariable regression model. More data are needed to better understand the long-term outcomes and better define the optimal timing of surgery in this patient population. [ABSTRACT FROM AUTHOR]

Background: The aim of this study is to investigate the prevalence of central sleep apneas syndrome (CSAS) in children with obstructive sleep apnea syndrome (OSAS) and the effect of adenotonsillectomy (A)TE on CSAS.Methods: Retrospective analysis of polysomnographic data in children diagnosed with OSAS and without comorbidity. A central apnea index (CAI) ≥1/h is considered abnormal and central sleep apnea syndrome (CSAS) is diagnosed at a CAI >5/h. Data are presented as median (25-75 percentile).Results: Data were available for 90 children, 35 girls and 55 boys, age 3.7 years (1.8-5.4), BMI-z score 0.20 (-0.85-0.90), oAHI 10.9/h (5.8-19.1). Sixty-four percent had an abnormal CAI and the prevalence of CSAS was 7.8%. There was a significant correlation between CAI and MinSat (r = -0.48, p = 0.01) and between CAI and age (r = -0.45, p = 0.01). Pre-postop PSG data were available for 41 children with a CAI ≥ 1/h. Central apnea index decreased from 2.2/h (1.7-3.8) to 1.3/h (0.8-2.6) (p < 0.001) following (A)TE along with an improvement in oAHI from 10.9/h (5.9-22.2) to 1.2/h (0.6-2.7) (p < 0.001). No patient had postoperative CSAS and a reduction in the CAI <1/h was observed in 11 patients (26,9%).Conclusion: A central apnea index ≥1/h is common in children with OSAS but CSAS (CAI >5) is rare. We observed a significant decrease in the CAI and a resolution of CSAS after (adeno)tonsillectomy. [ABSTRACT FROM AUTHOR]

Introduction: Non-iatrogenic trauma to the airway is rare and presents a significant challenge to the anaesthetist. Although guidelines for the management of the unanticipated difficult airway have been published, these do not make provision for the 'anticipated' difficult airway. This systematic review aims to inform best practice and suggest management options for different injury patterns.Methods: A literature search was conducted using Embase, Medline, and Google Scholar for papers after the year 2000 reporting on the acute airway management of adult patients who suffered airway trauma. Our protocol and search strategy are registered with and published by PROSPERO (http://www.crd.york.ac.uk/PROSPERO, ID: CRD42016032763).Results: A systematic literature search yielded 578 articles, of which a total of 148 full-text papers were reviewed. We present our results categorized by mechanism of injury: blunt, penetrating, blast, and burns.Conclusions: The hallmark of airway management with trauma to the airway is the maintenance of spontaneous ventilation, intubation under direct vision to avoid the creation of a false passage, and the avoidance of both intermittent positive pressure ventilation and cricoid pressure (the latter for laryngotracheal trauma only) during a rapid sequence induction. Management depends on available resources and time to perform airway assessment, investigations, and intervention (patients will be classified into one of three categories: no time, some time, or adequate time). Human factors, particularly the development of a shared mental model amongst the trauma team, are vital to mitigate risk and improve patient safety. [ABSTRACT FROM AUTHOR]

Purpose: Low temporal latency between a gating ON/OFF signal and the LINAC beam ON/OFF during respiratory gating is critical for patient safety. Here the authors describe a novel method to precisely measure gating lag times at high temporal resolutions. Methods: A respiratory gating simulator with an oscillating platform was modified to include a linear potentiometer for position measurement. A photon diode was placed at linear accelerator isocenter for beam output measurement. The output signals of the potentiometer and diode were recorded simultaneously at 2500 Hz with an analog to digital converter for four different commercial respiratory gating systems. The ON and OFF of the beam signal were located and compared to the expected gating window for both phase and position based gating and the temporal lag times extracted. Results: For phase based gating, a real-time position management (RPM) infrared marker tracking system with a single camera and a RPM system with a stereoscopic camera were measured to have mean gate ON/OFF lag times of 98/90 and 86/44 ms, respectively. For position based gating, an AlignRT 3D surface system and a Calypso magnetic fiducial tracking system were measured to have mean gate ON/OFF lag times of 356/529 and 209/60 ms, respectively. Conclusions: Temporal resolution of the method was high enough to allow characterization of individual gate cycles and was primary limited by the sampling speed of the data recording device. Significant variation of mean gate ON/OFF lag time was found between different gating systems. For certain gating devices, individual gating cycle lag times can vary significantly. [ABSTRACT FROM AUTHOR]

Abstract: Pompe disease, which leads to dysfunction of the enzyme acid a‐glucosidase, is a genetic disorder seen in 1 in 40000 births. Adult‐onset Pompe disease is known as a slowly progressive myasthenia with or without respiratory dysfunction. We herein report two cases of adult‐onset Pompe disease, in which postoperative acute respiratory failure was the the initial manifestation. The two patients showed no symptoms of ambulatory and respiratory dysfunction before operation. The diagnosis of Pompe disease was determined by muscle biopsy and acid a‐glucosidase assay in the blood. Rapid deterioration of already struggling diaphragmatic function induced by stress of surgery and anesthesia were thought to be the main reason of postoperative acute respiratory failure. Physicians should be aware of the existence of an adult form of Pompe disease which may present with postoperative acute respiratory failure. [ABSTRACT FROM AUTHOR]

Objectives With the emergence of propranolol as the primary treatment for hemangiomas the indications for surgical intervention have been greatly reduced. There remains a role for surgical management in those patients who fail medical therapy, particularly for hemangiomas involving the airway. Detailed is our experience with subglottic hemangiomas, including three patients who failed propranolol treatment and were successfully treated with surgical excision and single stage laryngotracheoplasty (LTP) with thyroid ala graft. Methods Retrospective case series (level of evidence: 4). Results Six patients were treated with propranolol for subglottic hemangiomas over a 6 year period (2008–2014). Three patients responded to propranolol therapy and required no adjunctive surgical procedures. Three patients failed propranolol treatment, and required open resection of their subglottic hemangiomas and thyroid ala graft placement. Indications for resection were complete lack of response to propranolol in one patient, and initial response to propranolol with subsequent regrowth in the other two patients. All three patients were treated with submucosal extirpation of their hemangioma and single stage LTP; hemangioma was confirmed in all cases by positive GLUT-1 staining. All three surgical patients were successfully extubated post-operatively and none had hemangioma regrowth. Conclusions Fifty percent of patients in our series did not have long-term response to propranolol for subglottic hemangioma, highlighting the importance of close follow-up. When identified early, subglottic hemangiomas refractory to propranolol treatment can be successfully addressed with single stage LTP and tracheotomy can be avoided. [ABSTRACT FROM AUTHOR]

Background and Aims: Supraglottic airway devices have been established in clinical anesthesia practice and have been previously shown to be safe and efficient. The objective of this prospective, randomized trial was to compare I-Gel with LMA-Proseal in anesthetized spontaneously breathing patients. Material and Methods: Sixty patients undergoing short surgical procedures were randomly assigned to I-gel (Group I) or LMA-Proseal (Group P). Anesthesia was induced with standard doses of propofol and the supraglottic airway device was inserted. We compared the ease and time required for insertion, airway sealing pressure and adverse events. Results: There were no significant differences in demographic and hemodynamic data. I-gel was significantly easier to insert than LMA-Proseal (P < 0.05) (Chi-square test). The mean time for insertion was more with Group P (41 + 09.41 secs) than with Group I (29.53 + 08.23 secs) (P < 0.05). Although the airway sealing pressure was significantly higher with Group P (25.73 + 02.21 cm of H2O), the airway sealing pressure of Group I (20.07 + 02.94 cm of H2O) was very well within normal limit (Student's t test). The success rate of first attempt insertion was more with Group I (P < 0.05). There was no evidence of airway trauma, regurgitation and aspiration. Sore throat was significantly more evident in Group P. Conclusion: I-Gel is a innovative supraglottic device with acceptable airway sealing pressure, easier to insert, less traumatic with lower incidence of sore throat. Hence I-Gel can be a good alternative to LMA-Proseal. [ABSTRACT FROM AUTHOR]

An eleven-year-old, 3-kg, intact female Maltese was presented for depression, anorexia and dyspnoea. Thoracic radiographs showed right-side pleural effusion, a vesicular emphysema pattern and consolidation of the right middle lung lobe. A presumptive diagnosis of lung lobe torsion (LLT) in the right middle lobe was made using a computed tomography scan. Thoracoscopic exploration was performed without one-lung ventilation in the right hemithorax. Pleural fluid and engorgement of the torsed lung lobe were observed. A total lung lobectomy of the right middle lung lobe was performed with a thoracoscopic-assisted procedure using hem-o-lok clips applied to the hilus. The dog was discharged three days after surgery, and no recurrence of the clinical signs of disease related to the respiratory system was observed during the follow-up time period of six months. Based on these findings, we conclude that thoracoscopic-assisted lung lobectomy using hem-o-lok clips is a minimally invasive surgical alternative to thoracotomy and successful operative intervention for lung lesions in small breed dogs. [ABSTRACT FROM AUTHOR]

The article focuses on a consensus on standardizing clinical end points in aortic arch surgery by the International Aortic Arch Surgery Study Group (IAASSG). Topics discussed include standardizing definitions, the impact of surgical techniques on patient outcomes, and management-oriented classification system for complications. It mentions classifications of clinical end points for several systems including the respiratory system, the cardiovascular system, and the neurological system.

Abstract: Introduction: Laryngotracheal reconstruction is a common procedure to repair subglottic stenosis. Despite a success rate upwards of 85%, this procedure has significant morbidity associated with it, specifically with the site of the graft harvest and recurrence of stenosis. We propose that a recently described cellular bioscaffold xenograft may be useful in reducing these complications. Methods and materials: 10 Sprague Dawley rats were divided into 2 groups of 5. One group underwent incision through the cricoid and the first two tracheal rings followed by primary closure (G1); the second group underwent incision through the cricoid and the first two tracheal rings followed by placement of the xenograft (G2); additionally, a specimen was harvested from an animal which did not undergo any surgical procedure to compare to the two surgical groups. Specimen harvest occurred on post-operative days 1, 7, 14, 21, and 28. Results: 6 of 10 animals provided usable data. All animals receiving the xenograft survived until the time of specimen harvest. Only 1 animal undergoing primary closure survived beyond post-operative day one. On histology review, the xenograft animals showed a progressive decrease in fibrosis relative to the animals that underwent primary closure. On POD 28, restoration of the respiratory epithelium and intact basement membrane was noted in the xenograft group. Conclusion: We believe that this pilot study shows the potential of utilizing bio-implantable biomaterials, specifically a cellular bioscaffold which encourages the ingrowth of native tissue instead of fibrosis. Histologic analysis shows that use of the xenograft can initiate the proliferation of native tissues decreasing the amount of fibrosis present post-operatively, although significant further analysis is needed before definitively concluding that this approach is superior to utilization of a graft. [Copyright &y& Elsevier]

Surgical management of hiatal hernias and complex gastroesophageal reflux disease (GERD) requires a tension free repair with reliable reflux control. The authors would like to emphasize their own technique patented by Professor Boţ?ianu, performed through a left thoracophrenotomy Through this simple and quick technique and without using a synthetic mesh thus avoiding rejection, the whole ensemble is fixed under the diaphragm. [ABSTRACT FROM AUTHOR]

We investigated the clinical characteristics, management modalities, and outcomes in patients with relapsing polychondritis (RP) with airway involvement. The medical records of RP patients with airway involvement seen at Samsung Medical Center from August 2004 to December 2011 were collected. The clinical manifestations were investigated retrospectively, including rheumatologic record, diagnostic tests, treatment modalities, and clinical outcomes. Twelve patients (five females, seven males) with a median age of 48(interquartile range (IQR) 44-60) years were included. All patients had airway involvement, including the trachea (100 %), main bronchi (83 %), and larynx (25 %). Rheumatological manifestations were frequent, including inflammatory arthritis (50 %), auricular chondritis (42 %), keratoconjunctivitis (42 %), nasal chondritis (42 %), saddle nose (25 %), and sensorineural hearing loss (17 %). All patients who had acute exacerbations were treated with high-dose corticosteroids (1,000 mg per day) and were maintained on oral prednisolone (5-40 mg per day), with weekly methotrexate (2.5-15 mg per week) during follow up. One out of 12 patients required mechanical ventilation. Nine patients have survived without ventilator support and eight patients without a tracheostomy. Two patients underwent a tracheostomy with endobronchial stenting. During follow-up (median 24[IQR 7-50] months), the clinical outcome was favorable in nine patients, while three patients died of pneumonia and respiratory failure. High-doses of corticosteroids during an acute exacerbation followed by maintenance prednisolone with methotrexate could be recommended as a therapeutic option in RP patients with airway involvement. Airway intervention by an experienced clinician is sometimes required. [ABSTRACT FROM AUTHOR]

The study advances the idea of using computational fluid dynamics in the process of planning surgical treatment modalities for patients with obstructive airway disorders. It is hypothesized that the a priori knowledge of the functional outcome of surgical intervention on the flow and airway resistance can guide the surgeon in choosing an effective surgical strategy. Computed tomography images spanning the respiratory tract of an adult patient with a combined glottic and subglottic stenosis are used to reconstruct three-dimensional geometrical models of the airway. Computational fluid dynamics is used to obtain airway flow patterns during inspiration and expiration in these models. Numerical predictions about flow velocity, pressure distribution on the airway lumen, wall shear stress, and airway resistance are obtained so that the relevance of each individual stenotic level is quantified. Four different virtual surgeries in different combinations are assessed in order to remedy the constricted airway. The virtual surgery based airway models are evaluated by comparisons with the pre-treatment flow modeling results. The predicted numerical data revealed that the removal of the constriction at the level of the vocal folds will have the most significant effect on the airway resistance. The flow simulations offer a quantitative method of evaluating the airway resistance in patients with combined glottic and subglottic stenoses. Predictions of airway resistances and other numerical calculations from different virtual surgeries give additional inputs for the surgeon, in deciding the most appropriate surgery on a case-by-case basis. [ABSTRACT FROM AUTHOR]

Aim To compare the developmental outcome of infants with oesophageal atresia with or without trachea-oesophageal fistula ( OA/ TOF) who underwent surgery in early infancy with healthy control infants in New South Wales, Australia. Methods Infants diagnosed with OA/ TOF requiring surgical intervention were enrolled prospectively between 1 August 2006 and the 31 December 2008. Healthy control infants were enrolled in the same time period. The children underwent a developmental assessment at 1 year of age (corrected) using the Bayley Scales of Infant and Toddler Development ( Version III). Results Of 34 infants with OA/ TOF that were enrolled, 31 had developmental assessments. The majority (75%) were term infants (≥37 weeks gestation) with a mean birth weight of 2717 g. Fourteen infants (44%) had an associated birth defect and one infant with multiple associated anomalies subsequently died. Developmental assessments were also performed on 62 control infants matched for gestational age. Infants with OA/ TOF had a mean score significantly lower on the expressive language subscale ( P < 0.05) compared with the control infants. Conclusions This study found a lower than expected developmental score for infants following surgery for OA/ TOF in the expressive language subscale compared with the healthy control infants. These findings support concerns over the potential impact of OA/ TOF and its effects on development. Further studies, including continuing developmental review to determine whether these differences persist and their functional importance, should be performed. [ABSTRACT FROM AUTHOR]

Abstract: Laryngotracheal stents may damage the highly complex laryngeal structures, impair voice and swallowing functions and cause tissue ingrowths, thereby necessitating airway patency interventions. In benign airway disease, the number of adolescents with laryngotracheal stents is therefore limited. We present two cases of laryngeal metallic stent placement following benign airway disease. Two adolescents presented with severe dyspnea and self-expandable metallic stent placement after benign laryngotracheal stenoses. Granulation tissue ingrowths required additional surgical interventions every 6–8 weeks to recanalize the stent lumen. We performed multi-stage surgery including removal of the embedded stent, segmental resection of the stenotic area, end-to-end-anastomosis and laryngotracheal reconstruction respectively, to achieve patent airway without tracheal cannulation. Montgomery T-tubes were temporarily inserted to bridge the complex reconstructions. In both adolescents, we achieved successful removal of the embedded stent and patent airway. Bilateral vocal fold paralysis required additional surgery to improve the final airway patency and vocal rehabilitation. Stent removal, segmental resection and laryngotracheal reconstruction provide the achievement of patent airway and allow decannulation. Temporary Montgomery T-tubes bridge complex laryngotracheal reconstructions. In benign laryngeal airway disease, stent placement should be avoided, especially in adolescents. Transfer to a specialist center should be considered prior to metallic stent implantation. In general, self-expanding tracheobronchial stents can be placed in selected patients where surgical interventions are limited. [Copyright &y& Elsevier]

Background: The most important consideration for administration of anesthesia in upper airway surgery is maintenance of a patient's airway for optimal surgical exposure, adequate ventilation and sufficient depth of anesthesia. The tubeless anesthetic techniques, including total intravenous anesthesia with a combination of propofol and remifentanil or inhalation anesthesia with the insuffation of anesthetic gas, are considered experimental in many countries. Methods: Fifteen pediatric (8 to 60 months) and 16 adult (23 to 55 years) patients were included in the study. Anesthesia (gas insuffation) was induced into the pediatric patients by inhalation of 8% sevofiurane in 8 L/min oxygen flow. An endotracheal tube, inserted through the nasal or oral cavity with its tip in the laryngopharynx, was used to maintain anesthesia with 3%-6% sevofiurane in 4 L/min oxygen flow. Total intravenous anesthesia was induced in adult patients by inhalation, 8% sevoflurane in 8 L/min oxygen flow, combined with intravenous injections of propofol (1.5-2 mg/kg) and fentanyl (1.5-2 μg/kg). Assisted ventilation was maintained by use of a face or laryngeal mask. Propofol infusion at 200-300 μg/kg/min, combined with remifentanil infusion at 0.06-0.2 μg/kg/min, was used for maintaining anesthesia. Results: All patients had surgery under tubeless anesthesia with steady spontaneous respiration. The mean time from induction of anesthesia to unconsciousness was 16±3 s and 36±14 s in pediatric and adult groups, respectively. The average times from induction of anesthesia to the attainment of necessary anesthetic level for surgery while keeping steady spontaneous respiration was 4.17±0.96 min and 8.69±3.17 min in pediatric and adult groups, respectively. The frequency and extent of respiration and heart rate were maintained within the normal range; SpO2 was >98%. None of the patients developed complications. Conclusion: Tubeless anesthesia with spontaneous ventilation induced in patientscan provide both an interference-free operative field and continuous observationof airway activity, which may provide an effective approach in excellent surgical conditions for the actual airway operation. [ABSTRACT FROM AUTHOR]

Background: In Germany there is currently no national standard for the management of patients with obstructive sleep apnea syndrome (OSAS). The object of this survey was to obtain information on the treatment concept for patients with OSAS and to report on the current practice in Germany. Methods: Data collection was obtained through an online questionnaire. A total of 12,113 members of the supporting anesthesia societies from all over Germany were invited to participate via e-mail. Additionally an announcement was made in a professional journal. Results: A total of 1,671 questionnaires were analyzed. The average age of the respondents was 45 years, 64% were male and 36% were female. The average work experience was 16 years and 85% of the respondents were consultants. In total 85% of anesthesiologists were predominantly working in inpatient care and 12% were predominantly active in outpatient care. Of the respondents 63% preferred regional anesthesia, 20% preferred general anesthesia for patients with OSAS and 17% did not have a preference for a specific anesthesia procedure. Outpatient surgery for patients with OSAS was performed by 72% of the respondents using regional anesthesia and by 55% of the respondents using local anesthesia with sedation. Of the anesthesiologists 49% consented to outpatient surgery using general anesthesia and 14% to interventions involving the airways. Compared to anesthesiologists working predominantly in inpatient departments, those working predominantly in outpatient departments treated patients with OSAS more frequently on an outpatient basis, used general anesthesia significantly more often, discharged those patients significantly earlier and observed less complications. Conclusions: This survey shows that outpatient surgery for patients with sleep apnea is common practice in Germany. It is also performed when patients have moderate or severe OSAS and for respiratory tract surgery. This means that the management is not conform to the guidelines of the American Society of Anesthesiologists (ASA). [ABSTRACT FROM AUTHOR]

General anaesthesia may affect the respiratory system in many different ways, resulting in intra-operative and post-operative pulmonary complications such as alteration of residual functional capacity and atelectasis. The aim of this review is: 1) to analyse different proposed strategies of protective mechanical ventilation during general anaesthesia for laparoscopic, openabdominal and cardiac surgery and 2) to overview the different ventilatory modes commonly used during general anaesthesia in the operating room. [ABSTRACT FROM AUTHOR]

Whether the outcome of primary spontaneous pneumothorax (PSP) when treated with needlescopic video-assisted thoracic surgery is positive is still under scrutiny. The present study was conducted to compare the needlescopic approach with the conventional approach. One-hundred and six patients with primary spontaneous pneumothorax who had undergone needlescopic video-assisted thoracic surgery (NVATS) between May 2006 and August 2008 were reviewed. Their age, gender, smoking status, BMI, side of attack, operative indications, operative time, intraoperative blood loss, postoperative length of stay, postoperative pain in visual analog scale (VAS), postoperative recurrence and follow-up period were recorded. These data were compared with those of 89 patients with PSP who had undergone conventional video-assisted thoracic surgery (CVATS) between June 2002 and April 2006. The operative time was shorter (NVATS: 82.36 ± 35.58 min, CVATS: 99.78 ± 35.74 min; p = 0.008) and intraoperative blood loss was less (NVATS: 16.67 ± 25.90 ml, CVATS: 24.36 ± 26.86 ml; p = 0.04) for the NVATS group. The postoperative pain in VAS was significantly less in NVATS. No major complication or mortality was found in either group. For treatment of primary spontaneous pneumothorax, NVATS is a safe and effective option. Further, it has the added benefit of less pain and improved cosmetics. [ABSTRACT FROM AUTHOR]

Primary spontaneous pneumothorax (PSP) is by definition not associated with any underlying lung disease. However, this does not mean that there is no underlying pathological process. It has become increasingly apparent over recent years that PSP is associated with diffuse and often bilateral abnormalities within the pleura and is not simply a disease caused by ruptured blebs/bullae. The pathological process includes emphysema-like changes, pleural porosity and inflammation. In this review, we summarise the recent advances in our understanding of the pathogenesis of PSP and discuss how this relates to management strategies for patients with PSP. Copyright © 2012 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Erdheim-Chester disease (ECD) is a rare non-Langerhans cell histiocytosis most commonly characterized by symmetrical skeletal involvement and may present with pulmonary involvement leading to chronically progressive pulmonary symptoms. Characteristics on chest radiography include non-specific findings of diffuse interstitial and pleural thickening, micronodules, ground-glass opacities and parenchymal condensation as a result of infiltration by lipid-laden histiocytes. We present the case of a 50-year-old man with ECD presenting with acute pulmonary symptoms due to rupture of a large cystic lesion with resultant pneumothorax. He was brought by ambulance to our hospital, complaining of acute anterior chest pain and severe dyspnea. Chest radiography showed right-sided pneumothorax with a collapsed lung, a large, left-sided cystic lesion in the upper lung field and accentuated interstitial markings. Bullectomy and surgical biopsy were performed, demonstrating histologically histiocytic infiltrates that were strongly positive for CD68, but negative for S-100 protein and CD1a. Subsequent systemic examinations indicated widespread symmetrical skeletal involvement, leading to a definitive diagnosis of ECD. Copyright © 2011 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background: Lung sequestration is a rare congenital pulmonary disorder and is usually diagnosed in children with recurrent pulmonary infections. Lung sequestrations are not commonly found to be a cause of respiratory symptoms in adults. Objectives: It was the aim of this study to show that pulmonary sequestration is rare in advanced age and can be accompanied by severe pulmonary symptoms. Methods: We conducted a case series analysis of patient characteristics, symptoms, diagnosis and treatment of 11 adults with a lung sequestration at the Thoraxklinik Heidelberg between 2001 and 2009. Results: From 2001 to 2009, intralobar lung sequestration was diagnosed and treated in 11 adults aged 19 to 58 years with an average age of 39.9 ± 11.3 years and a male:female distribution of 5:6. In 3 patients (27.3%), the predominant symptom was hemoptysis. Recurrent pulmonary infections occurred in 1 patient (9.1%); pneumonia and lung abscess were detected in 2 patients (18.2%). In 3 cases (27.3%), dry cough was the predominant symptom, and in only 2 cases (18.2%), lung sequestration was asymptomatic. Eight patients (72.7%) were diagnosed by imaging techniques prior to surgery. In 3 cases (27.3%), diagnosis was made intraoperatively and by pathological examination. Surgical intervention included 7 lobectomies (63.6%), 3 wedge resections (27.3%) and 1 (9.1%) segmentectomy. Conclusion: Lung sequestration in adults is rare, but it can cause severe pulmonary symptoms. In cases of recurrent pulmonary infections of identical localization or recurrent hemoptysis, lung sequestration should be considered in order for the diagnosis to be made rapidly. Surgical resection is the treatment of choice. Copyright © 2011 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background: Bispectral index (BIS) is a valuable tool for assessing the depth of sedation and guiding the administration of sedative drugs. We previously demonstrated the benefits of BIS-guided propofol sedation in patients undergoing flexible bronchoscopy. Objective: To examine the feasibility and safety profile of propofol sedation in patients undergoing medical thoracoscopy (MT). Methods: Patients undergoing MT for diagnostic evaluation or treatment of pleuropulmonary diseases were enrolled over a 2-year period. Nurses and chest physicians were trained by anesthetists to provide analgosedation, to detect and correct cardiopulmonary disturbances. The level of sedation was optimized individually by titrating the propofol infusion according to the BIS and clinical evaluation. Patients' clinical data, procedure time, medications and any adverse events were recorded. Results: Fifty-three patients (60% male) with a median age of 62 years (range 19-84 years) underwent MT. The operative procedure lasted a median time of 28 min (range 9-112 min). The median doses of anesthetic drugs were 145 mg of propofol (range 20-410 mg) and 84 μg of fentanyl (range 0-225 μg). Hemodynamic disturbances occurred in 39 patients (bradycardia n = 4, tachycardia n = 12, hypotension n = 34) and required drug administration in only 4 cases. Hypoxemic events (n = 4) resolved upon gentle patient stimulation (verbal command, chin lift, oral cannula). All patients could be discharged from the recovery unit within 105 min after the procedure. Conclusions: BIS-guided propofol sedation is a safe method that might replace midazolam sedation in MT and can be managed by well-trained nonanesthesiologist personnel. Copyright © 2011 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Tracheomalacia after thyroidectomy is a life-threatening situation. However, it is difficult to predict postoperative tracheal obstruction with certainty. A case of a 74-year-old woman with a long-standing adenomatous goiter (98 g) is reported. She had undergone partial right lobe thyroidectomy 54 years earlier. After total thyroidectomy, she was reintubated and required a tracheostomy because of tracheomalacia. The right residual thyroid tumor weighed only 5 g, but it extended to the retrotracheal space. Because the right lobe had stretched the membranous wall of the trachea over a long period of time, the tracheal lumen was thought to have collapsed because of loss of the foundation of the tracheal cartilage (the residual right lobe) along with the supportive surrounding tissue (the left lobe) after surgery. The present case suggests that the occurrence of tracheomalacia could be attributed to reoperation and retrotracheal extension. Thus far, six preoperative predictive factors for the development of severe postoperative respiratory obstruction have been reported: goiter for more than 5 years, preoperative recurrent laryngeal nerve palsy, significant tracheal narrowing and/or deviation, retrosternal extension, difficult endotracheal intubation, and thyroid cancer. Two more factors, reoperation and retrotracheal extension of tumor, may also be risks for airway obstruction after thyroidectomy. [ABSTRACT FROM AUTHOR]

Objective. To examine the role of CT scans and early surgical intervention in the management of pediatric patients with primary spontaneous pneumothorax (PSP). Methods . Retrospective cohort study. Results. The authors identified 46 cases with 70 episodes of pneumothorax. The recurrence rate among conservatively treated patients was 50% both after the first and the subsequent episode. Recurrence rate in cases with and without blebs on CT was comparable. Initial episodes were treated with supplemental oxygen (n = 18) and chest tube drainage (n = 18), and 10 patients underwent video-assisted thoracoscopic surgery (VATS). The recurrence rate was significantly lower following surgical intervention compared with other therapy, and morbidity was comparable with that in patients who needed chest tube drainage. Conclusions. Recurrence after the first episode of PSP in children is frequent and is difficult to predict by CT findings. VATS is safe and effective in preventing recurrences. Surgical intervention may be an attractive alternative in patients who require chest tube drainage for the first episode of PSP. [ABSTRACT FROM PUBLISHER]

We report a 12-year-old boy who underwent stent implantation into the left main bronchus at the age of 9.5 years for palliation of severe bronchial stenosis. He had developed complete obstruction of the stent by granulation tissue resulting in respiratory deterioration and the requirement of mechanical ventilation. The stent obstruction was treated at the age of 11.5 years by cryorecanalization. In this technique, cooling of the tip of the cryoprobe is used to induce adherence of the obstructing tissue allowing the subsequent removal of tissue particles by retraction of the probe. Under general anesthesia, a miniaturized cryoprobe was advanced via the working channel of a flexible bronchoscope. Repeat maneuvers of freezing and retraction resulted in complete recanalization of the stent. Repeat bronchoscopies 4 and 12 weeks later revealed recurrent formation of some granulation tissue which was removed by repeat cryorecanalization. Seven months after the initial procedure there was a complete patency of the stent. According to our experience, cryorecanalization is a safe and effective alternative for the treatment of stent obstruction by granulation tissue. Due to the introduction of a miniaturized probe, this method is well applicable in children since it can be performed via the working channel of a flexible pediatric bronchoscope. Copyright © 2011 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Thoracoscopy is currently the gold standard for the diagnosis and treatment of pleural diseases. Its diagnostic yield is 95% in patients with malignant pleural disease, with approximately 90% successful pleurodesis for malignant pleural effusion and 95% for pneumothorax. At the same time, thoracoscopy constitutes an important tool in the research of pleural pathophysiology and molecular biology. The improvement of technology has provided important tools to thoracoscopy, such as autofluorescence, narrow band imaging, and infrared light, used in clinical and basic research in many disorders involving the pleura. For these reasons, training in thoracoscopy should be considered equally important as training in bronchoscopy for residents in respiratory medicine. Copyright © 2011 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

The triad of micrognathia, glossoptosis, and resultant airway obstruction is known as Robin sequence (RS). Although RS is a well-recognized clinical entity, there is wide variability in the diagnosis and care of children born with RS. Systematic evaluations of treatments and clinical outcomes for children with RS are lacking despite the advances in clinical care over the past 20 years. We explore the pathogenesis, developmental and genetic models, morphology, and syndromes and malformations associated with RS. Current classification systems for RS do not account for the heterogeneity among infants with RS, and they do not allow for prediction of the optimal management course for an individual child. Although upper airway obstruction for some infants with RS can be treated adequately with positioning, other children may require a tracheostomy. Care must be customized for each patient with RS, and health care providers must understand the anatomy and mechanism of airway obstruction to develop an individualized treatment plan to improve breathing and achieve optimal growth and development. In this article we provide a comprehensive overview of evaluation strategies and therapeutic options for children born with RS. We also propose a conceptual treatment protocol to guide the provider who is caring for a child with RS [ABSTRACT FROM AUTHOR]

Abstract: The article starts by describing the gross anatomy of the trachea and bronchial tree, the pleura and the lungs. The blood supply, lymphatic drainage and innervation are included, with brief reference to the microstructure of the respiratory system. The gross anatomy, blood supply and innervation of the diaphragm conclude the article. [Copyright &y& Elsevier]

Objective:To examine the histological effects of radiofrequency thermal ablation on the inferior concha epithelium and subepithelium, over five years post-treatment.Method:Inferior nasal concha epithelial biopsy specimens were examined histologically before and four, 30, 48 and 60 months after radiofrequency treatment, in six patients with inferior nasal concha hypertrophy.Results:At four months post-treatment, there was proliferation of blood vessels, increased inflammatory cells and a slightly decreased number of glands. At 30 months post-treatment, the number of inflammatory cells and glands had decreased, but signs of increased vascular proliferation, fibrosis and granulation were seen. At 48 and 60 months post-treatment, the number of inflammatory cells and blood vessels had decreased significantly, the number of glands had increased, and lobulation was observed.Conclusion:Radiofrequency thermal ablation does not cause carbonisation or osteitis in the inferior concha. The resultant fibrosis causes contraction of the concha and only minor tissue destruction (as shown by the persistence of submucosal glands). [ABSTRACT FROM PUBLISHER]

Conclusions: Nasal congestion caused by mucosal swelling and conch hypertrophy impairs breathing and causes snoring and headaches. Treatment of conch hypertrophy with radiofrequency (RF) allows reduction of mucosal swelling, minimization of hyperplasia, and decreased mucus production. This treatment provides a clinically significant improvement in snoring, headaches, and mouth breathing. Objective: To compare the efficacy of RF surgery to nasal steroid; each method used separately and both in combination. Methods: This was a consecutive randomized study, which included 84 patients with 3 outpatient visits, where the first visit included a complete medical history, assessment of ENT status, and skin tests. Nasal flow measured with rhinomanometry was done at the first visit and then before and after each treatment. Patients were asked to respond to a questionnaire at the first visit and after each subsequent treatment. Thereafter the variables were analyzed with established statistical methods. Results: Measurement of variables and patient questionnaire responses showed a clear improvement in several symptoms, such as sneezing and headache, and a clinically significant improvement in nasal congestion and snoring. [ABSTRACT FROM AUTHOR]

Objectives: I report further experience with arytenoid abduction (AAb), a procedure that enlarges the glottis by external rotation of the arytenoid cartilage and thus moves the vocal process laterally and rostrally, but does not preclude adduction for phonation. Therefore, AAb has the potential to preserve voice in patients with bilateral abductor laryngeal paralysis. Methods: I performed a retrospective review of AAb in 11 patients with bilateral laryngeal paralysis and 3 patients with other neurologic causes of glottal airway compromise, ie, adductor breathing dystonia, frequent laryngospasm, and progressive laryngeal breathing dysfunction. Results: Seven of the 11 patients with bilateral paralysis had dramatic airway improvement. One patient required a tracheotomy after AAb, and 3 patients with an existing tracheotomy could not be decannulated. Arytenoid abduction relieved airway obstruction in the patient with recurrent laryngospasm and in the child with progressive laryngeal breathing dysfunction, but the patient with adductor breathing dystonia has persistent stridor. The factors associated with a poor airway outcome included prolonged tracheotomy, electromyographic evidence of inspiratory activity of adductor muscles, chronic obstructive pulmonary disease, sleep apnea. and prior cordotomy or arytenoidectomy. Conclusions: Arytenoid abduction is most effective in patients with bilateral laryngeal paralysis of less than 1 year's duration who do not have unfavorable laryngeal adductor activity. [ABSTRACT FROM AUTHOR]

Purpose: To clarify the clinical significance of sivelestat sodium (SIV) administration, we surveyed the status of 40 patients treated with SIV for respiratory dysfunction following surgery. Methods: The subjects were patients who received SIV administration due to systemic inflammatory response syndrome (SIRS) and respiratory dysfunction (PaO/FO ratio ≤300 mmHg) after surgery at the Department of Surgery and Science, Kyushu University, and related facilities between April and December 2008. Results: The most frequent underlying condition was perforation of the digestive tract, followed by cancer of the upper digestive organs. The main causes of SIRS were surgical stress and infection. The mean P/F ratio at the initiation of SIV administration was 185.5 ± 72.0 mmHg. The ratio increased, and the number of SIRS-related factors decreased with time after SIV administration. Sivelestat sodium was administered within 24 h after the onset of respiratory dysfunction in 87.5% of the patients, and the survival rate at 28 days after the initiation of SIV administration was 90.0%. Conclusion: Our findings suggest that multidisciplinary postoperative management, including the administration of SIV, during the early phase after the onset of respiratory dysfunction leads to improvements in respiratory function and survival. [ABSTRACT FROM AUTHOR]

Objectives: This study was designed to evaluate the efficacy and morbidity of immediate tonsillectomy used to treat peritonsillar abscess (quinsy) and parapharyngeal abscess. Subjects and method: This four-year, retrospective study was based on 31 patients hospitalised in a university hospital ENT and head and neck surgery department for peritonsillar and/or parapharyngeal abscess. All patients underwent immediate, bilateral tonsillectomy. The length of hospital stay, duration of antibiotic therapy, microbiological findings, complications, and the time to complete recovery and oropharyngeal healing were recorded. Results: The patients' mean post-tonsillectomy hospital stay was 2.84 days (median: 3 days). No post- operative haemorrhage was observed. All patients were considered to be cured at the day 10 follow-up visit, and complete oropharyngeal healing was observed at the day 21 visit. The duration of antibiotic therapy ranged from 10 to 15 days (mean: 11.5 days; median: 10 days). Discussion and conclusion: Immediate tonsillectomy appears to be a safe and effective surgical technique for the management of peritonsillar and parapharyngeal abscess; in particular, it markedly reduces patients' hospital stay (when performed early in the course of the disease) and duration of antibiotic therapy. Immediate tonsillectomy has become the first-line treatment for parapharyngeal abscess and several types of peritonsillar abscess in our department. [ABSTRACT FROM AUTHOR]

Objectives: This study analyzed the incidence and characteristics of bilateral peritonsillar abscesses (PTAs) that were treated with immediate tonsillectomy. Methods: The study analyzed 409 patients with PTAs treated between 1984 and 2008. The patients included 304 male and 105 female patients between 2 and 85 years of age (median age. 30 years). Immediate tonsillectomy was performed in 371 of the PTA patients (90.7%). The incidence of bilateral PTAs and candidate predictive factors for bilateral PTAs were reviewed, including age, duration of PTA symptoms, history of recurrent tonsillitis, history of PTAs, deviation of the uvula, body temperature on admission, white blood cell count on admission, and C-reactive protein level on admission. Results: Bilateral PTAs were found in 24 of 371 patients (6.5%). Younger age, absence of a deviated uvula, and a higher C-reactive protein value were the clinical features associated with bilateral PTAs in multivariate analysis. Conclusions: The occurrence of bilateral PTAs was not rare; this fact has to be taken into consideration in discussing therapeutic concepts. The clinical features of bilateral PTAs suggested that bilateral PTAs might be a part of (he natural history of PTAs, and that they occur in cases in which there is a delay in diagnosis and treatment. Further study is necessary to confirm the causation of bilateral PTAs. [ABSTRACT FROM AUTHOR]

Background: CT -guided percutaneous transthoracic fine needle aspiration biopsy (TFNAB) has become a widely accepted and effective minimally invasive technique for the diagnosis of a variety of intrathoracic lesions that are not readily accessible with bronchoscopy. It is generally regarded as a safe procedure with limited morbidity and extremely rare mortality. It provides high diagnostic accuracy and has a relatively low complications rate. Objectives: The aims of our study were to report our experience with regard to the accuracy & pneumothorax rate of percutaneous CT-guided biopsy of solitary pulmonary nodules using automatic biopsy gun. Patients and methods: Between January 2006 and August 2009, 54 patients (46 men and 8 women) with solitary pulmonary nodule underwent CT guided transthoracic biopsy at Al-Kadhimyia teaching hospital, Baghdad, Iraq. All the lesions could not be diagnosed with fiberoptic bronchoscopy. CT-guided biopsy was performed with an 18-gauge automatic biopsy gun. Chest radiography was done 2-4hr later and 24hr after biopsy for observation of pneumothorax. The overall diagnostic accuracy, pneumothorax rate, and chest tube insertion rate were determined. Diagnostic accuracy and pneumothorax rate were statistically compared according to lesion size & lesion depth (p value of less than 0.05 was considered to be significant). Results: Forty one patients (76%) diagnosed as malignant (diagnostic accuracy of 87.8%). Thirteen patients (24%) were diagnosed as benign (diagnostic accuracy of 92.3%). The overall diagnostic accuracy was 89% (48 of 54). The diagnostic accuracy did not differ with respect to the lesions size and lesions depth from the chest wall. Accurate diagnosis was made in 25 of the 29 nodules <20 mm (86%) and in 23 of the 25 nodules ≥20 mm (92%). Similarly accurate diagnosis was made for 36 (90%) of the 40 nodules shallower than 60 mm and for 12 (85.7%) of the 14 nodules ≥60 mm. Pneumothorax occurred in 23 (42%) patients. Pneumothorax occurred more frequently in small sized lesions (16 out of 29 lesions measuring <20 mm) as compared to (7 out of 25 lesions ≥20 mm) (P <0.05). similarly pneumothorax occurred more frequently in deeper lesions (10 out of 14 lesions ≥60mm in depth) as compared to (13 out of 40 lesions <60 mm in depth) (P <0.05). Only 7 (13%) patients requiring thoracostomy tube placement. Conclusions: CT- guided biopsy using automatic biopsy gun allowing a specific diagnosis for benign & probably malignant lesions. Diagnostic accuracy was not affected by the size and depth of the lesions. Deeper & small sized lesions have associated with an increased rate of pneumothorax. [ABSTRACT FROM AUTHOR]

Objective: To discuss the aetiology and determine the optimal surgical treatment of catamenial pneumothorax. Methods: Between January 1980 and December 2007, 17 patients with catamenial pneumothorax were treated at our institution. Regarding the surgical approach, thoracotomy was performed until 1991, and thoracoscopic surgery was performed from 1992 onward. Results: Pneumothorax was on the right side in all but two patients. Surgery was performed on 15 of the 17 patients. The surgical procedure was a diaphragm resection plus a partial bleb resection in eight patients, a diaphragm resection in two patients, a diaphragm resection plus an absorbable polyglycolic acid sheet in four patients, and a partial bleb resection in one patient. Five patients demonstrated a postoperative recurrence (33.0%). However, no recurrence has been observed thus far in the four patients with an absorbable polyglycolic sheet placed on the diaphragmatic surface. Conclusion: Although the postoperative recurrence rate of patients undergoing surgical procedures remains high, there were some patients with no postoperative recurrence. Placement of an absorbable sheet on the diaphragmatic surface may therefore prevent recurrence of catamenial pneumothorax. [ABSTRACT FROM AUTHOR]

To evaluate the stroboscopic and acoustic results obtained with larynx fiberendoscopic surgery (LFS) to remove pedunculated vocal fold polyps. Prospective study, comparing before and after surgery results. We used a series of 31 patients, with a pedicled vocal fold polyp. To remove the pedunculated polyp, we used LFS. This technique consists of excising vocal fold injuries under local anaesthesia by means of micro tweezers using a canal larynx fiberscope. Subjects were evaluated on three occasions: before surgery, 2 and 4 weeks after surgery. After surgery, improvement obtained in stroboscopy examination was statistically significant ( p < 0.001) and 100% of the patients had recovered a mucosal wave. After 4 weeks of surgery, all acoustic parameters reached normality ranges. LFS used for the removal of pedunculated vocal fold polyps produces acoustic and stroboscopic improvements, comparable to those obtained using direct laryngoscopy. [ABSTRACT FROM AUTHOR]

Abstract: Objective: The aim of this paper is to study the respiratory muscle strength by evaluating the maximal inspiratory pressure (MIP), maximal expiratory pressure (MEP) and lung volume before and 3 and 6 months after adenotonsillectomy. This is an interventional, before and after trial. It was set at the Department of Otolaryngology, University of São Paulo, School of Medicine. We included 29 children (6–13 years old), both genders, consecutively recruited from the waiting list for adenotonsillectomy. Children were submitted to maximal inspiratory pressures (MIP), maximal expiratory pressure (MEP) evaluation using an analog manovacuometer, lung volume, using incentive expirotometer and thoracic and abdominal perimeter using a centimeter tape. Children were evaluated in 3 different moments: 1 week before and 3 and 6 months after surgery. Results: MIP improved significantly 3 months (p <0.001) after adenotonsillectomy and MEP did not change (p =1). There were increases in lung volume (p =000), chest (p =0.017) and abdominal perimeter (p =0.05). Six months after surgery, all parameters improved. MIP (p =0), MEP (p =0), lung volume (p =0.02), chest (p =0.034) and abdominal perimeter (p =0.23). Conclusion: This study suggests that there was an improvement in respiratory muscular strength, once there was a significant improvement in maximal inspiratory pressure, lung volume and other parameters after adenotonsillectomy. [Copyright &y& Elsevier]

Benign acquired esophagorespiratory fistulas (BERFs) represent a broad spectrum of anatomic pathology presenting in a wide variety of clinical settings. These fistulas can lead to severe respiratory compromise and rarely close spontaneously. Surgical fistula closure has been the traditional therapeutic approach, but is associated with significant morbidity and mortality. The recent advent of endoscopic technologies suggests that minimally invasive procedures may offer a safe alternative to surgery for the treatment of esophagorespiratory fistulas. In this article, we present our experience in treating complex benign esophagorespiratory fistulas of diverse etiologies utilizing a primarily minimal invasive, endoscopic, or combined surgical and endoscopic approaches. Our experience demonstrates that an endoscopic-based approach is safe and technically feasible and can, potentially, spare a subset of patients from open surgery. A multidisciplinary decision-making process, based on individualized parameters, is a prerequisite for a successful outcome. [ABSTRACT FROM AUTHOR]

Background: Tension pneumothorax requires emergent decompression. Unfortunately, some needle thoracostomies (NTs) are unsuccessful because of insufficient catheter length. All previous studies have used thickness of the chest wall (based on cadaver studies, ultrasonography or computed tomography [CT]) to extrapolate probable catheter effectiveness. The objective of this clinical study was to identify the frequency of NT failure with various catheter lengths. Methods: We evaluated the records of all patients with severe blunt injury who had a prehospital NT before arrival at a level-1 trauma centre over a 48-month period. Patients were divided into 2 groups: helicopter (4.5-cm catheter sheath) and ground ambulance (3.2 cm) transport. Success of the NT was confirmed by the absence of a large pneumothorax on subsequent thoracic ultrasonography and CT. Results: Needle thoracostomy decompression was attempted in 1.5% (142/9689) of patients. Among patients with blunt injuries, the incidence was 1.4% (101/7073). Patients transported by helicopter (74%) received a 4.5-cm sheath. The remainder (26% ground transport) received a 3.2-cm catheter. A minority in each group (helicopter 15%, ground 28%) underwent immediate chest tube insertion (before thoracic ultrasound) because of ongoing hemodynamic instabilityi' Failure to decompress the pleural space by NT was observed via ultrasound and/or CT in 65% (17/26) of attempts with a 3.2-cin catheter, compared with only 4% (3/75) of attempts with a 4.5-cm catheter (p< 0.001). Conclusion: Tension pneumothorax decompression using a 3.2-cm catheter was unsuccessful in up to 65% of cases. When a larger 4.5-cm catheter was used, fewer procedures (4%) failed. Thoracic ultrasonography can be used to confirm NT placement. [ABSTRACT FROM AUTHOR]

Abstract: Objective: The objective of this paper is to present our surgical experience with a cohort of four infants with laryngotracheoesophageal cleft (LTEC) in order to highlight our early failures and complications and to propose a comprehensive, three-layered approach in treating stages III and IV LTEC. Method: An IRB approved, retrospective chart review was carried out of a cohort of four cases occurring within a 2-year period of time. Results: All patients had other significant anomalies, and the mortality rate was high: 75%. After our initial failures and difficulties with recurrent fistulas, tracheomalacia and tracheotomy dependence, we were able to achieve a successful outcome of a functional separation of the airway and the digestive tract without a tracheotomy in our last two patients. Unfortunately, both these patients died from factors not directly associated with the LTEC so long-term follow up was not possible. We now have one survivor, our second case, who is tracheotomy dependent. Conclusion: Laryngotracheoesophageal clefts are rare congenital anomalies with high morbidity and mortality despite various forms of surgical repair. Fistulas, tracheostomy dependence, tracheomalacia, and chronic lung disease secondary to aspiration are frequent problems following LTEC repairs. We advocate an anterior approach to the cleft repair, a three-layered closure of the cleft to include an interpositional muscular flap, and a physiologic repair of the posterior larynx with a standard cartilage graft technique used in laryngotracheal reconstruction. [Copyright &y& Elsevier]

Summary: Spontaneous pneumothorax is an extremely frequent pathology. Despite this, there is still no clear consensus on managing these patients. Therefore, we perform a systematic review and meta-analysis of the effectiveness of percutaneous aspiration compared with tube drainage for treating idiopathic spontaneous pneumothorax. Controlled, randomised clinical trials were selected, in which the effectiveness of percutaneous aspiration is compared with that of chest tube drainage, in terms of resolution of the pneumothorax and rates of relapse and hospital admission. Relevant articles were identified by searching electronic databases (e.g., Medline, EMBASE, CENTRAL, mRCT and Pascal), as well as the references of the papers found in this manner, with a cut-off date of April 2009. Quality was assessed by two independent evaluators, using the CASPe appraisal tool. Effectiveness of percutaneous aspiration is compared with that of chest tube drainage, in terms of resolution of the pneumothorax and rates of relapse and hospital admission. [Copyright &y& Elsevier]

Abstract: Vagus nerve stimulation (VNS) for medically refractory seizures has been an approved therapy by the Food and Drug Administration since 1997, with additional approval as an adjunct therapy for major depression granted in 2005. Potential applications for VNS therapy in obesity, neuropsychiatric disorders, and chronic pain syndromes are under investigation. Bradyarrhythmias, including asystole, may occur during VNS device placement or as a delayed complication. A peritracheal hematoma may develop following VNS device placement, necessitating emergent management. Other respiratory complications may include vocal cord movement abnormalities with potential for aspiration. Vagus nerve stimulation results in sleep-related breathing pattern changes, with an associated increase in the number of obstructive apneas and hypopneas in both children and adults, which may impact perioperative care. [Copyright &y& Elsevier]

Summary: Evidence is accumulating regarding the local opioid regulation of physiologic respiratory functions. However, anatomical evidence for a local opioid network of the respiratory system is scarce. In this study, tissue samples from 12 lung cancer patients undergoing lobectomy or pneumonectomy were examined immunohistochemically for the expression of the opioid network components met-enkephalin, the respective precursor proenkephalin, the key processing enzymes prohormone convertases 1 and 2, carboxypeptidase E, and the δ opioid receptor in different areas of human lung. Colocalization of proenkephalin with met-enkephalin, prohormone convertase 1, prohormone convertase 2, and carboxypeptidase E was demonstrated by double-immunofluorescence confocal microscopy in alveolar macrophages, submucosal glands, cancerous cells, and pulmonary neuroendocrine cells of bronchial epithelium. Corresponding δ opioid receptor was identified on cells of all these functionally relevant anatomical structures and on substance P–immunoreactive sensory nerve fibers arborizing within bronchial epithelium. Our findings provide evidence of a local opioid network, that is, the exact anatomical localization of proenkephalin, its functionally active peptide met-enkephalin, and the key processing enzymes as well as corresponding δ opioid receptor, linked to functionally important structures of the respiratory system. These findings encourage future studies to examine the functional role of local opioid peptides within the respiratory system. [Copyright &y& Elsevier]

Abstract: Objective: This study aims to determine the differences among various diaphragmatic eventration (DE) aetiologies and to compare the outcomes of the operation relative to the use of a diaphragmatic patch. Methods: Between 2003 and 2009, 28 patients with a DE who underwent surgery were classified according to the following aetiology: (a) previous operation or disease, (b) congenital/idiopathic and (c) trauma. Patients who received diaphragmatic patches during their operations (plication+patch, P/P, 19 cases) were compared with the patients receiving sole plication during the operation (P, 9 cases). The operations had been performed through a minimal length lateral thoracotomy incision (12–14cm). Results: The mean age of the patients was 53.3±9.8 years. A high hemi-diaphragm (alone or associated with a blunt sinus or a wide mediastinum) was the most prominent chest X-ray (CXR) finding in 19 patients (68%). The postoperative mean forced expiratory volume in 1s (FEV1) value (2.1±0.7) and the dyspnoea score (1.8±0.7) were better than the preoperative values (1.7±0.6; 3.4±0.9, respectively). The average height of the diaphragm (7.8±3.1cm) was not correlated with the dyspnoea score and the FEV1 value. Postoperative complications (4/28 or 14.3%) were minimal, excluding one respiratory insufficiency. The mean follow-up time was 23.4±17.8 months. Patients with congenital aetiology were younger, had higher diaphragms, had earlier operations after symptoms started and had better preoperative FEV1 values. P/P operations were done later than P operations. The P/P method patients had shorter postoperative hospital stays than the P method patients. Two diaphragmatic events (recurrence and herniation) occurred after the operations were performed with the P method. Conclusions: Buttressing the diaphragm by patch after the plication can protect from recurrence of a DE or any diaphragmatic insufficiency. Previous abdominal interventions may increase the complication rate after a DE operation. [Copyright &y& Elsevier]

Background: To report our experience for the treatment of lung tumors of the right main bronchus (RMB) invading the carina. Methods: From February 2000 till January 2007 we have identified 8 cases (1.09%) requiring carinal surgery. Plan of action: Close cooperation with anaesthetics, long flexible ET tube, Right posterolateral thoracotomy, no irrevocable steps until resection guaranteed, mobilization of trachea and main bronchus, division of the trachea & Left main bronchus. Intubate across surgical field. Tailoring for airway size discrepancies, appropriately. Construction of the tracheobronchial anastomosis around the ventilatory tube. Skillfull reintubation, over a long boogie. Results: Mortality: 12.5% due to ARDS (one patient) Morbidity: anastomotic stenosis requiring stent (one patient). Follow-up 52 ± 11 months. Recurrences: 2 patients (both with pathological N2 disease on histology). Conclusions: Success of carinal surgery depends on careful patient selection, team approach and attention to detail. Patients with N2 disease carry the worst prognosis. [ABSTRACT FROM AUTHOR]

Objective: Optimizing alveolar recruitment by alveolar recruitment strategy (ARS) and maintaining lung volume with adequate positive end-expiratory pressure (PEEP) allow preventing ventilator-induced lung injury (VILI). Knowing that PEEP has its most beneficial effects when dynamic compliance of respiratory system (Crs) is maximized, we hypothesize that the use of 8 cm H2O PEEP with ARS results in an increase in Crs and end-expiratory lung volume (EELV) compared to 8 cm H2O PEEP without ARS and to zero PEEP in pediatric patients undergoing cardiac surgery for congenital heart disease. Methods: Twenty consecutive children were studied. Three different ventilation strategies were applied to each patient in the following order: 0 cm H2O PEEP, 8 cm H2O PEEP without an ARS, and 8 cm H2O PEEP with a standardized ARS. At the end of each ventilation strategy, Crs, EELV, and arterial blood gases were measured. Results: EELV, Crs, and PaO2/FiO2 ratio changed significantly ( P < 0.001) with the application of 8 cm H2O + ARS. Mean PaCO2– PETCO2 difference between 0 PEEP and 8 cm H2O PEEP + ARS was also significant ( P < 0.05). Conclusion: An alveolar recruitment strategy with relative high PEEP significantly improves Crs, oxygenation, PaCO2– PETCO2 difference, and EELV in pediatric patients undergoing cardiac surgery for congenital heart disease. [ABSTRACT FROM AUTHOR]