Sternothoracotomy for combined coronary artery bypass grafting and left upper lobectomy in a patient with low-lying tracheostoma.
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A 64-year-old man had a low-lying tracheostoma and presented with unstable angina and a mass in the pulmonary left upper lobe. Simultaneous coronary revascularization and resection of the lung neoplasm were completed through a sternothoracotomy (clam-shell) incision. The advantages of this approach include excellent exposure to the mediastinum and the lung fields, and the option of using both internal thoracic arteries for bypass grafting. (+info)
The difference between delayed extubation and tracheostomy in post-operative sleep apnea after glossectomy or laryngectomy.
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BACKGROUND: Patients with cancer of the tongue or larynx require glossectomies or laryngectomies and subsequent reconstruction. These procedures remove part of the patient's upper airway. In cancer of the tongue, the removed part of the airway is substituted by a flap of their skin. Post-operatively, it is possible that the patients have problems respiring comfortably. In addition to this, long surgical procedures may simply interfere with their circadian rhythm. To elucidate the possible change in their post-operative respiration, we monitored the patient's respiratory pattern with an apnea monitor. METHODS: We attached an apnea monitor to the patients and recorded their respiratory pattern and arterial oxygen saturation. The patients were monitored for a total of five days: three days prior to the operation, one day before the operation, the day of operation, two days after, and on the fourth day after the operation. The period of monitoring was from 8:00 p.m. to 6:00 a.m. the next morning. RESULTS: Sixteen patients completed this study. The patients whose tube was extubated after glossectomy showed frequent apnea, low mean oxygen saturation and low comfort score as compared to the patients with tracheostomy after laryngectomy. Because two failed cases of free skin flap were among the former, it is possible that the frequent apnea is a factor of failed free skin graft after glossectomy and laryngectomy. CONCLUSION: Further studies are required to improve the patient's respiration during their sleep after tracheal extubation in glossectomy. (+info)
Polymyositis with respiratory muscle weakness requiring mechanical ventilation in a patient with metastatic thymoma treated with octreotide.
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Although most patients with thymoma present with a mediastinal mass amenable to surgical resection, some patients develop metastatic disease requiring systemic therapy. The majority of thymomas express somatostatin receptors as demonstrated by octreotide scanning, an observation which has prompted the clinical use of octreotide in patients with this disease. Many patients with thymoma exhibit autoimmune paraneoplastic syndromes, most frequently myesthenia gravis. We report here the case of a patient with metastatic thymoma who developed a profound autoimmune polymyositis and lupus-like syndrome that flared following treatment with octreotide and was associated with a clinical response to this agent. No evidence for myesthenia gravis was discovered. The severity of the myopathy necessitated mechanical ventilation for 12 weeks. The natural history of thymoma, treatment options including recent combination chemotherapy regimens, and potential mechanisms for flaring of autoimmune paraneoplastic syndromes triggered by therapy of thymoma are discussed. (+info)
Percutaneous versus surgical tracheostomy: a double-blind randomized trial.
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OBJECTIVE: To compare surgical (SgT) and percutaneous (PcT) tracheostomies. BACKGROUND: Percutaneous tracheostomy has been said to provide numerous advantages over classical SgT. METHODS: A prospective randomized trial with a double-blind evaluation was used to compare SgT and PcT. SgT and PcT were performed according to established techniques (n = 70). The procedure was performed at the bedside in the intensive care unit in 21 cases (30%). The outcome measures were divided into procedure-related variables, perioperative complications, and postoperative complications. The procedure-related variables (location, duration, and difficulty) were evaluated by the surgeon. The perioperative and postoperative complications were divided into serious, intermediate, and minor. Perioperative and early postoperative (14 days) complications were evaluated daily by an intensive care unit nurse blinded to the technique used. Long-term postoperative complications were evaluated 3 months after decannulation by a surgeon blinded to the surgical technique. RESULTS: There were no major complications in either group. Most variables studied were not statistically different between the PcT and SgT groups. The only variables to reach statistical significance were the size of the incision (smaller with PcT, p < 0.0001), minor perioperative complications (greater with PcT, p = 0.02), and difficult cannula changes (greater with PcT; p < 0.05). Among nonsignificant differences, difficult procedures and false passages were more frequent with PcT, whereas long-term unesthetic scars were more frequent with SgT. CONCLUSIONS: Both techniques are associated with a low rate of serious or intermediate complications when performed by experienced surgeons. There were more minor perioperative complications with PcT and more minor long term complications with SgT. (+info)
A regional survey of emergency surgery: the trainees' perspective.
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The reduction of junior doctors' hours and the 'Calmanisation' of higher surgical trainees have led to an inevitable decrease in clinical experience. The development of subspecialisation within general surgery limits the diversity of elective operative experience, while the resident surgical registrar continues to be faced by the same range of emergencies. Procedures such as tracheostomy, thoracotomy and emergency burr hole, although rare in an emergency setting, are seldom seen by surgical trainees outside ENT, cardiothoracic and neurosurgical departments, respectively. However, these life saving procedures continue to be within the remit of the general surgeon, and were considered as essential knowledge in the operative viva of the FRCS examination. (+info)
Percutaneous (Portex) tracheostomy: an audit of the Newcastle experience.
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The purpose of this study was to audit the results of percutaneous tracheostomies performed by ENT surgeons in Newcastle. During a 3-year period, 298 tracheostomies: 196 percutaneous and 102 open were studied. A complication rate for percutaneous tracheostomy was found to be 10% compared to 8% for open, this difference was not statistically significant chi 2 = 0.279, P = 0.598 (DF = 1). The indications for percutaneous tracheostomy were mainly limited to respiratory support for intensive care unit patients, whereas the majority of open tracheostomies were performed in the operating theatre. The results of this audit suggest that percutaneous tracheostomy is the method of choice for respiratory support in the intensive care unit and is as safe as the open technique. (+info)
Laryngeal mask airway and fibre-optic tracheal inspection in thyroid surgery: a method for timely identification of tracheomalacia requiring tracheostomy.
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Use of the laryngeal mask airway combined with fibre-optic laryngoscopy in thyroid surgery was first described in 1991. In this unit, it has been successfully used in over 130 cases. The advantages in identification and preservation of the recurrent laryngeal nerves using this technique have been demonstrated. However, to date, no report exists of a further advantage, namely the management of tracheomalacia. (+info)
A single-center 8-year experience with percutaneous dilational tracheostomy.
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OBJECTIVE: To determine surgical, postoperative, and postdischarge complications associated with percutaneous dilational tracheostomy (PDT) in an 8-year experience at the University of Kentucky. SUMMARY BACKGROUND DATA: There are known risks associated with the transport of critically ill patients to the operating room for elective tracheostomy, and less-than-optimal conditions may interfere with open bedside tracheostomy. PDT has been introduced as an alternative to open tracheostomy. Despite information supporting its safety and utility, the technique has been criticized because advocates had not provided sufficient information regarding complications. METHODS: A prospective database was initiated on all patients who underwent PDT between September 1990 and May 1998. The database provided indication, procedure time, duration of intubation before PDT, and intraoperative and postoperative complications. Retrospective review of medical records and phone interviews provided long-term follow-up information. RESULTS: In the 8-year period, 827 PDTs were performed in 824 patients. Two patients were excluded because PDT could not be completed for technical reasons. There were 519 male and 305 female patients. Mean age was 56 years. Prolonged mechanical ventilatory support was the most common indication. Mean procedure time was 15 minutes, and the average duration of intubation before PDT was 10 days. The intraoperative complication rate was 6%, with premature extubation the most common complication. The procedure-related death rate was 0.6%. Postoperative complications were found in 5%, with bleeding the most common. With a mean follow-up of greater than 1 year, the tracheal stenosis rate was 1.6%. CONCLUSIONS: On the basis of this large, single-center study, the authors conclude that when performed by experienced surgeons, PDT is a safe and effective alternative to open surgical tracheostomy for intubated patients who require elective tracheostomy. (+info)