1/14. Total excision of the sternum and thoracic pedicle transposition of the greater omentum; useful strategems in managing severe mediastinal infection following open heart surgery.Mediastinal sepsis following open heart surgery is a significant cause of death. Open drainage of the mediastinumalone was employed originally in management of this problem. More recently, debridement, drainage, and reclosure have been used. Various irrigation solutions, such as antibiotics and Betadine, have been advocated to control severe mediastinal sepsis. Three principles of management in patients unresponsiveness to the above techniques have proved successful in two patients with life-threatening mediastinal sepsis: (1) radical, complete excision of the sternum and adjacent costal cartilages; (2) transposition of the greater omentum on a vascular pedicle to the mediastinum; and (3) primary closure with full-thickness rotational skin flaps. The radical excision of the sternum removes residual foci of sepsis in cartilage and sternal bone marrow. The transposition of the omentum provides a highly vascular, rapidly granulating covering for the contaminated great vessels and hase been successfully to prevent recurrence of suture line bleeding of an exposed ascending aortic anastomosis site. Primary closure of the wound with full-thickness skin flaps provides a suprisingly satisfactory covering for the heart. Preoperative and postoperative measurements of ventilatory mechanics have shown relatively small ventilatory impairment after the alteration of the thoracic cage imposed by excision of the sternum. Two patients have returned to active lives. A treatment failure probably due to incomplete adherence to these guidelines also is presented.- - - - - - - - - - ranking = 1keywords = vessel (Clic here for more details about this article) |
2/14. Innominate artery rupture after transcervical drainage for descending necrotizing mediastinitis.We present a case of innominate artery rupture after descending necrotizing mediastinitis (DNM) on day 36 of cervicomediastinal drainage. The patient recovered after aortosubclavian arterial bypass grafting followed by resection of the eroded artery. Because mechanical pressure caused by drains in addition to the inflammatory process can cause major vessel erosion, prolonged transcervical tube drainage for treating descending necrotizing mediastinitis should be avoided even if the drains applied are soft and thin.- - - - - - - - - - ranking = 1keywords = vessel (Clic here for more details about this article) |
3/14. Aortoesophageal fistula associated with tuberculous mediastinitis, mimicking esophageal Dieulafoy's disease.Aortoesophageal fistula is a rare and lethal disorder that may result from primary diseases of aorta or esophagus, aortic bypass graft, ingestion of foreign body, trauma, surgical procedure or instrumentation. Tuberculous fistula is extremely rare. We present a 27-yr-old female patient with aortoesophageal fistula associated with tuberculous mediastinitis. The patient experienced massive hematemesis and esophagoscopy revealed a small mucosal defect with exudate-coated blood vessel like Dieulafoy 's lesion on about 25 cm from the incisor teeth. Despite two sessions of endoscopic hemostatic procedures, active massive hemorrhage recurred and was controlled effectively with a prompt insertion of Sengstaken-Blakemore tube. The patient underwent open thoracotomy, which revealed aortoesophageal fistula. Numerous white-yellowish, millet seed-like tubercles were scattered in pleural and abdominal cavity. Division of fistular tract and esophageal resection with Ivor-Lewis anastomosis were performed. Histopathologic study confirmed tuberculous pleuritis and peritonitis. The patient died of postoperative pulmonary complication.- - - - - - - - - - ranking = 1keywords = vessel (Clic here for more details about this article) |
4/14. mediastinitis after percutaneous dilatational tracheostomy.In our experience, PDT after total arch replacement, especially after dissection of neck vessels, should be approached with caution. A long skin incision that allows discharge to drain from the wound and a sufficiently long postoperative tracheostomy period to allow tissue healing in the neck are necessary for prevention of mediastinitis.- - - - - - - - - - ranking = 1keywords = vessel (Clic here for more details about this article) |
5/14. Endobronchial findings of fibrosing mediastinitis.Fibrosing mediastinitis is underdiagnosed because of the nonspecific character of the presenting symptoms. The endobronchial findings obtained via flexible bronchoscopy are not defined in the literature. We describe 3 cases of fibrosing mediastinitis, most likely caused by histoplasmosis. All 3 patients presented with hemoptysis and were found to have tracheobronchial concentric narrowing, severe hyperemia, and mucosal edema. The hyperemic blood vessels were treated with neodymium yttrium-aluminum-garnet (Nd:YAG) laser and argon plasma coagulation. We believe that recognition of specific endobronchial findings aids in prompt diagnosis of fibrosing mediastinitis.- - - - - - - - - - ranking = 1keywords = vessel (Clic here for more details about this article) |
6/14. Fatal massive hemorrhage caused by nasogastric tube misplacement in a patient with mediastinitis.Nasogastric tube insertion is a routine procedure in medical care. However, misplacement of the tube can cause a variety of complications, which can be life threatening in some instances. We report a case of fatal hemorrhagic shock immediately after nasogastric tube insertion in a patient undergoing debridement by video-assisted thoracoscopic surgery for mediastinitis. Emergency endoscopy showed that the bleeding came from the nasogastric tube which had perforated the esophagus and possibly tore an intrathoracic large vessel. The nasogastric tube insertion was considered to have directly produced the perforation because no esophageal perforation had been found on preoperative endoscopy. Factors contributing to the risk of esophageal perforation in this case included coexisting mediastinitis, surgical manipulation, endotracheal intubation, inability to cooperate during general anesthesia, and repetitive advancement of the nasogastric tube. Prompt clamping of the nasogastric tube or delayed insertion after failed attempts might have improved the outcome. This report illustrates the complication of massive bleeding that can occur immediately after misplaced insertion of a nasogastric tube. Extraordinary care should be taken to avoid misplacement of the nasogastric tube during insertion.- - - - - - - - - - ranking = 1keywords = vessel (Clic here for more details about this article) |
7/14. Unilateral pulmonary edema due to pulmonary venous obstruction from fibrosing mediastinitis.An unusual case of fibrosing mediastinitis with obstruction of the inferior and superior left pulmonary veins and severe narrowing of the right pulmonary artery, disclosed after unilateral pulmonary edema, is described. The 18-year-old male patient had a long history of cough, progressive dyspnea and recurrent hemoptysis and the possible diagnosis of "interstitial fibrosis" from a previous lung biopsy. The diagnosis and the pulmonary vessels involvement were suspected after right heart catheterization combined with transesophageal echocardiography and confirmed during urgent thoracotomy and at postmortem examination.- - - - - - - - - - ranking = 1keywords = vessel (Clic here for more details about this article) |
8/14. Immediate muscle flap coverage for repair of cardiac rupture associated with mediastinitis.Sternal wound infection with mediastinitis is a dreaded complication of cardiac surgery. Even more devastating is perforation of the heart or great vessels secondary to advanced mediastinitis. The exsanguinating hemorrhage and presence of extensive infection usually lead to a poor salvage rate in these patients. Citations in the English literature of successful management of cardiac rupture associated with mediastinitis are, as expected, scare. Recently, the capability for immediate muscle flap coverage in the repair of associated rupture of the heart secondary to active mediastinal infection has been discussed in two reports. This article presents another report, in which bilateral pectoralis major muscle flaps were used successfully in salvage of a patient who sustained rupture of the right ventricle after debridement of an extensively purulent sternal wound and mediastinum.- - - - - - - - - - ranking = 1keywords = vessel (Clic here for more details about this article) |
9/14. Transposition of the greater omentum for management of mediastinal infection following orthotopic heart transplantation: a case report.A case of mediastinal infection following orthotopic heart transplantation is presented. A general survey of the available surgical management of this complication is given and an alternative operation involving extra-abdominal transposition of the greater omentum pedicled on the left gastroepiploic vessels is suggested for treating difficult cases.- - - - - - - - - - ranking = 1keywords = vessel (Clic here for more details about this article) |
10/14. Fibrosing mediastinitis complicating coronary artery surgery. Use of the descending thoracic aorta.This case illustrates the previously unreported combination of severe fibrosing mediastinitis involving the entire intrapericardial aorta, pulmonary artery, and innominate artery in a patient requiring coronary revascularization for chronic angina and multivessel coronary artery disease. Due to the mediastinal fibrosis, normal revascularization procedures and myocardial preservation techniques were altered and are described.- - - - - - - - - - ranking = 1keywords = vessel (Clic here for more details about this article) |
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