THE TREATMENT OF MEDIASTINAL TUMORS

Because there can be no certainty of diagnosis without it, thoracotomy is indicated in cases in which there is roentgenographic evidence of mediastinal tumor. “Watchful waiting” is considered unwise because the tumor may be malignant when first observed or may later undergo malignant change. Even if the lesion is and remains benign, an increase in the size of the mass may cause obstructive pressures necessitating operation ultimately. Moreover, infection and inflammation may develop at the site during prolonged observation, making operation more difficult.The hazards of thoracotomy, which have been greatly reduced in the last few years, are less than the hazards of waiting.     

Cancer of the lung: what should be the present approach?

The best opportunities at present for improving the results in the treatment of patients with cancer of the lung are by way of (a) utilizing the information obtained on routine x-ray examination of the chest, (b) decreasing the delay between the time of the first symptoms and the time the patient consults a physician, and (c) decreasing the delay between the time the patient first consults a physician and the time the cancer is surgically removed. The medical profession must increase its index of suspicion of cancer of the lung and persist in efforts to make a diagnosis when lung cancer is suspected. Exploratory thoracotomy should be used in suspicious cases when the diagnosis cannot be established by other methods.     

CANCER OF THE LUNG—What Should Be the Present Approach?

The best opportunities at present for improving the results in the treatment of patients with cancer of the lung are by way of (a) utilizing the information obtained on routine x-ray examination of the chest, (b) decreasing the delay between the time of the first symptoms and the time the patient consults a physician, and (c) decreasing the delay between the time the patient first consults a physician and the time the cancer is surgically removed.The medical profession must increase its index of suspicion of cancer of the lung and persist in efforts to make a diagnosis when lung cancer is suspected.Exploratory thoracotomy should be used in suspicious cases when the diagnosis cannot be established by other methods.     

Diaphragmatic herniation of the liver in macaques demonstrated by intravenous hepatography.

A suspected diagnosis of diaphragmatic herniation of the liver in 2 monkeys (Macaca fascicularis and Macaca mulatta) was confirmed radiographically by using various contrast media. Experimental compound AG 60.99, which is selectively concentrated in the liver and spleen, allowed excellent visualization of these 2 organs and confirmed the presence of a portion of the liver in the right thorax. Cholografin Meglumine was subsequently utilized to determine the location of the gall bladder. Other potential uses for AG 60.99 were discussed.     

Radiological Diagnosis of Congenital Diaphragmatic Hernia in 17th Century Korean Mummy

Congenital diaphragmatic hernia (CDH) is a birth defect of the diaphragm resulting in pulmonary sequelae that threaten the lives of infants. In computed tomography (CT) images of a 17th century middle-aged male mummy (the Andong mummy), we observed that the abdominal contents had protruded into the right thoracic cavity through the diaphragmatic defect, accompanied by a mediastinal shift to the left. On autopsy, the defect in the right posterolateral aspect of the diaphragm was reconfirmed, as was the herniation of the abdominal organs. The herniated contents included the right lobe of the liver, the pyloric part of the stomach, a part of the greater omentum, and the right colic flexure connecting the superior part of the ascending colon and the right part of the transverse colon. Taking our CT and autopsy results together, this case was diagnosed as the Bochdalek-type CDH. Herein we make the first ever report of a CT-assisted diagnosis of a pre-modern historical case of CDH. Our results show the promising utility of this modality in investigations of mummified human remains archaeologically obtained.     

Emergency prehospital on-scene thoracotomy: a novel method

The necessity for prehospital thoracotomy is rare, but can be lifesaving. Occasionally an emergency practitioner or surgeon coincidentally arrives at a trauma scene before the arrival of emergency medical teams. In such a circumstance, even when thoracotomy may be indicated, it is not usually performed in view of the lack of equipment (e.g., dissecting tools or rib retractor). We present a novel technique of "L" shape thoracotomy, or Thoraco-sterno-costochondrotomy, whereby in a prehospital setting, and with minimal equipment (such as a penknife) a thoracotomy can be performed with adequate exposure of the heart and great vessels. The similarities of this pragmatic procedure are considered within the context of ancient Aztec and Mesoamerican thoracotomies.     

电视胸腔镜在闭合性胸外伤诊治中的应用

目的:探讨电视胸腔镜手术(video-assisted thoracoscopic surgery,VATS)在闭合性胸外伤中诊断、治疗中的价值。方法:2004年6月～2011年6月选择68例闭合性胸外伤患者,应用VATS进行探查、诊断,同时进行肺修补、肺楔形切除、肋间血管止血、肋骨骨折固定等操作以及小切口辅助手术。结果:68例经VATS探查损伤情况:肺裂伤30例,凝固性血胸15例,肋间血管损伤10例,肋骨骨折需手术复位、固定12例,肺内血肿形成5例,膈疝3例,胸廓内血管损伤2例。VATS行肺修补术25例,肺楔形切除术7例,血管止血术12例,肋骨骨折复位、固定术12例,VATS辅助胸壁小切口肺叶切除术3例,膈疝修补术3例。VATS手术时间25～125 min,平均71.7 min。术后1～7 d胸腔少量积液、积气9例,少量咯血8例。68例随访2～17个月,平均9.2个月,复查胸片显示患肺复张良好,胸腔无积液、积气。结论:闭合性胸外伤患者应用VTAS诊治,可使诊断及时、准确,患者创伤小、恢复快,疗效满意。     

Clinical-genealogic analysis of diaphragmatic hernias]

The results of clinical-genetic examination of 174 probands with congenital diaphragmatic hernias and their families are presented. Genetic heterogeneity of diaphragmatic hernias, the spectrum of inherited syndromes obtained in the present study and shown in literature the spectrum and frequency of congenital malformations accompanying diaphragmatic hernias were shown. No increase in the average age of the probands' parents and in the marriage distances changes was observed both for isolated diaphragmatic hernias and those accompanied by other malformations was observed. Because of the high risk of neural tube defects occurrence in the sibs of children with diaphragmatic hernias, the probands' mothers should be recommended to undergo prenatal diagnosis of their further pregnancies for this character. The evidence of multifactorial inheritance for the most of diaphragmatic hernia cases was obtained. Empirical recurrent risk for probands' sibs was 1.54 + 1.5%.     

THE MANAGEMENT OF CHYLOTHORAX

Chylothorax is readily diagnosed from the characteristic qualities of the effusion. Treatment should initially be conservative, consisting of multiple aspirations followed, if necessary, by suction drainage.Approximately half of the patients will not respond to these measures, and direct ligation and division of the duct is necessary for cure. This operation is most readily carried out through the right chest, the thoracic duct being ligated just above the diaphragm. In cases in which the duct is surrounded by tumor, radiotherapy to the mediastinum is often successful in controlling the reaccumulation of chyle, but irradiation is generally not recommended until after a tissue diagnosis has been made by thoracotomy.Nutritional problems are often concomitants of chylothorax.     

The management of chylothorax

Chylothorax is readily diagnosed from the characteristic qualities of the effusion. Treatment should initially be conservative, consisting of multiple aspirations followed, if necessary, by suction drainage. Approximately half of the patients will not respond to these measures, and direct ligation and division of the duct is necessary for cure. This operation is most readily carried out through the right chest, the thoracic duct being ligated just above the diaphragm. In cases in which the duct is surrounded by tumor, radiotherapy to the mediastinum is often successful in controlling the reaccumulation of chyle, but irradiation is generally not recommended until after a tissue diagnosis has been made by thoracotomy. Nutritional problems are often concomitants of chylothorax.     

Diaphragmatic hernia associated with strangulation of the small bowel in an Atacamena mummy

This is the second case of a diaphragmatic herniafrom 200 autopsies of mummies of Atacamena Indians found in northern Chile. This case is noted in an individual who died in the third century A.D. as a result of strangulation of two loops of the jejunum that entered the thoracic cavity. The herniation was probably congenital in nature.     

极外型腰椎间盘突出症诊治研究

探讨极外型腰椎阃盘突出症的诊断及最佳手术治疗方法。对7例根据临床表现及CT检查诊断为极外型腰椎阃盘突出症的患者行椎管内外联合入路摘除髓核组织,解除神经根的压迫。经过3个月-3年的随访,基本恢复正常,能从事原体力工作,效果满意。结果表明CT扫描是诊断极外型腰椎间盘突出症的较好方法。一旦确诊宜尽早手术,椎管内外联合入路是治疗极外型腰椎阃盘突出症的最佳手术方法。     

Sonomicrometric regional diaphragmatic shortening in awake sheep after thoracic surgery

Through a right thoracotomy in seven sheep we chronically implanted sonomicrometry crystals and electromyographic electrodes in the costal and crural diaphragmatic regions. Awake sheep were studied during recovery for 4-6 wk, both during quiet breathing (QB) and during CO2 rebreathing. Tidal volume, respiratory frequency, and esophageal and gastric pressures were studied before and after surgery. Normalized resting length (LFRC) was significantly decreased for the costal segment on postoperative day 1 compared with postoperative day 28. Fractional costal shortening both during QB and at 10% end-tidal CO2 (ETCO2) increased significantly from postoperative days 1 to 28, whereas crural shortening did not change during QB but progressively increased at 10% ETCO2. Maximal costal shortening during electrophrenic stimulation was constant at 40% LFRC during recovery, although maximal crural shortening increased from 23 to 32% LFRC. Minute ventilation, tidal volume, and transdiaphragmatic pressure at 10% ETCO2 increased progressively after thoracotomy until postoperative day 28. Our results suggest there is profound diaphragmatic inhibition after thoracotomy and crystal implantation in sheep that requires at least 3-4 wk for stable recovery.     

THE APPLICATION AND EVALUATION OF PERITONEOSCOPY

Peritoneoscopic examination has now been accepted throughout the world as a safe diagnostic procedure in lieu of laparotomy in selected cases.Laparotomies for diagnostic purposes alone should be condemned.Peritoneoscopy should not be done without a definite purpose and the procedure should not be expected to accomplish more than the purpose for which it is done. Indications for the procedure are set forth in detail. Experience has established definite contraindications, which are reviewed.The procedure is especially indicated for patients who are aged, emaciated, anemic, or poor surgical risks for any reason.All patients having ascites of undetermined cause should be examined by peritoneoscopy.The method is especially indicated for examination of patients with liver disease of all types, for pelvic examinations, for use to determine existence of ectopic pregnancy, and for tumor localization.Considerable use was made of the procedure during World War II to determine the extent and site of intra-abdominal injuries caused by crushing, explosions, and falls from high places.The procedure permits early and correct diagnosis, early decision as to the advisability of operation, and determination as to operability in cases of malignant gastric lesions. It is a safe method for obtaining biopsy specimens from intra-abdominal tissue and organs.Accuracy of diagnosis in cases in which the method can be used is considerably greater with peritoneoscopic examination than with clinical information alone.     

ENDOSCOPY IN HERNIA AT THE ESOPHAGEAL HIATUS

Endoscopy is useful for confirming diagnosis of hiatal hernia as made by x-ray examination, for establishing the diagnosis when x-ray examinations do not disclose the herniation, and for observation of resultant abnormalities in the affected area. The authors'' experience with gastroscopy and esophagoscopy in hiatal hernia is reported and the techniques and usual findings in these procedures are summarized.     

Myocardial abscess complicating healed myocardial infarction.

An isolated myocardial abscess due to Bacteroides fragilis developed in the scar of a myocardial infarction. Fever, chills and signs of pericarditis were the main clinical features. Mild enteritis 1 week prior to the onset of symptoms related to the abscess was the most likely cause of the bacteremia. The diagnosis was established at thoracotomy, performed because of cardiac tamponade. Thirteen other cases of isolated bacterial myocardial abscess accompanying myocardial infarction have been reported, but all the infarctions were recent. Surgical resection for a suspected myocardial abscess should be considered in view of the high mortality, largely from cardiac rupture.     

Scalene node biopsy; an analysis of 42 cases

Scalene node biopsy was done in 42 patients with previously undiagnosed intrathoracic lesions. A definite histologic diagnosis was obtained in 25 patients. Scalene node biopsy is not only a valuable diagnostic procedure for intrathoracic lesions, but many times it may obviate the necessity of exploratory thoracotomy. If a diagnosis of carcinoma of lung is established by scalene node biopsy, the operability of the patient and the type of pulmonary resection should be carefully evaluated.     

Torsion of the Testis and its Appendages

In a survey of 101 cases with an index diagnosis of torsion of the testis or its appendage, there were 86 instances of torsion of the testis and 14 of torsion of the hydatid of Morgagni. In 38 of the patients with testicular torsion there were one or more “warning” attacks of pain and swelling, due to torsion which became spontaneously untwisted. In 19 cases operative fixation was performed because of this warning history, and all the testes were preserved. In the other 19 the testes were not explored until the patient came in with a severe “classical” episode of torsion: seven of these testicles were lost from gangrene or delayed atrophy.In 31 cases torsion resulted in failure to save the testis. Of these, 20 were misdiagnosed and treated initially as epididymo-orchitis, despite there being no evidence of a urinary tract infection. There is no excuse for not exploring any actuely inflammed testicle which is unaccompanied by definite evidence of urinary or urethral infection.     

SCALENE NODE BIOPSY—An Analysis of 42 Cases

Scalene node biopsy was done in 42 patients with previously undiagnosed intrathoracic lesions. A definite histologic diagnosis was obtained in 25 patients.Scalene node biopsy is not only a valuable diagnostic procedure for intrathoracic lesions, but many times it may obviate the necessity of exploratory thoracotomy. If a diagnosis of carcinoma of lung is established by scalene node biopsy, the operability of the patient and the type of pulmonary resection should be carefully evaluated.