سید رضاثاقبی

Chylothorax, is a relatively rare cause of pleural effusion in children. It can cause significant respiratory morbidity, as well as lead to malnutrition, metabolic disorder and immunodeficiency. Thus, a chylothorax requires timely diagnosis and treatment. In this case report beside review of literature we present the case of a person with chylothorax that incidentally found to have diffused thoracic lymphangiomatosis.

Elstofibroma dorsi is a benign and rare tumor that grows in dorsal aspect of thoracic cage muscles. In some patients this occurrence is bilateral. We present a 62 years old farmer man who referred due to a mass in dorsal part of right hemi thorax and inferior to scapula. After pathologic and radiologic evaluation an approximately 6×6 cm tumor was resected with free pathologic margins that final pathologic report was compatible with elastofibroma dorsi. Nearly after one year another tumor appeared in symmetrically in left side beneath scapula that the diagnosis of elastofibroma dorsi was assumed by CT and MRI. Patient was asymptomatic so follow up and observation selected for patient.

Human Lung hydatid cyst is a health problem in endemic area. Lung is the second most common organ after liver to be involved by parasite. Human is accidental intermediate host whom is infected by orally take up the primary host egg-containig feces, vegetables and water. Surgery is the treatment of choice but medical therapy is indicated in the case of exclusion from surgery. In this article, lung’s hydatid disease and its treatment are reviewed.

Lung re-transplantation is a technically difficult procedure، but it becomes necessary in some patients with previous lung transplantation. Our patient was a 25 years old man with emphysema and alpha-1 antitrypsin deficiency، and had right side single lung transplantation 6 years ago. After 3 years of first operation pulmonary indexes gradually declined and with the diagnosis of Obliterans Bronchiolitis، he was treated by immunosuppressive medication and antibiotics. But with more decline in pulmonary function، frequent rejections and fibrosis، patient became dependent on supplemental oxygen، and re-transplantation was considered to be the only efficient treatment. Finally patient underwent left side lung transplantation، 6 years after his first lung transplantation.

A 43 years old woman was admitted، complaining from cough and bloody sputum. In the chest radiography and pulmonary CT scan، perforated hydatid cyst was reported. Because the patient was asymptomatic and because radiography indicated that cysts were drained spontaneously، non-surgical treatment was recommended. This treatment included the administration of albendazole 400 mg twice daily. Patient did not develop any symptoms and no radiological changes in the first 18 months follow up.

Rigid broncoscopic dilatation is the lifesaving method for management of severe tracheal stenosis carried out under general anesthesia. However, for both anesthesiologist and bronchosco-pist, this procedure represents a most challenging practice. Inhalational induction which maintains spontaneous ventilation is commonly recommended in these patients. However, it needs a long time to reach the appropriate levels of anesthesia, and also airway instrumentation can precipitate coughing and complete airway obstruction. This paper describes our experience with rigid bronchoscopic dilation procedures performed with intravenous rapid induction of anesthesia in patients with severe postintubation tracheal stenosis. We conducted a retros-pective chart review of one hundred patients with severe post intubation tracheal stenosis who underwent rigid bronchoscopy for dilation of stenosis under general anesthesia at Masih Daneshvari and Kasra hospitals from Nov. 2011 to Sep. 2012. A rapid sequence induction of anesthesia was performed by intravenous injection of sodium thiopental and succinylcholine. Then an appropriate size of rigid bronchoscope was introduced into the trachea. If the airway was secured, dilatation of stenosis was done serially by different sizes of rigid bronchoscopes. Demographic, stenosis characteris-tics, and complications were recorded. There were 76 males and 24 females with mean age of 31.5±17.5 years. Following induction of anesthesia, the airway was rapidly secured in the first attempt with rigid bronchoscope in 97 patients. In 3 patients insertion of rigid bronchoscope was encountered with some problems, although airway control was done well and no major complications occurred. The intravenous rapid sequence induction of anesthesia by use of succinylcholine is safe for rigid brochoscopic dilatation in patients with severe post intubation tracheal stenosis. Close communication between the anesthesia and surgical teams are mandatory for the safe outcome of this procedure.

Pulmonary hydatid cyst (cystic echinococcosis) is a parasitic infection caused by Echinococcus species and is a major health threat in endemic areas such as Iran. In most cases, there is a single cysts in one lung, but in 4% of cases lung cysts are bilateral. Treatment of bilateral lung cysts is controversial and is associated with some problems. We operated on a ten years old girl with two large cyst in both lungs in one stage through two anterolateral thoracotomies and present the treatment results.Key Words:

Introduction & Tracheal disruption due to penetrating and blunt trauma is rare. Delayed diagnosis and treatment can lead to major morbidity and even death. The aim of this study was to assess the treatment and its outcome in 10 patients with trachea and larynx disruption. We studied 8 cases of tracheal disruption and 2 cases of larynx disruption which، were treated in our department during 8 years (April 2003- March 2011). Eight patients were immediately transferred and treated in our department and 2 were referred from other departments after initial treatments. The first priority for patients with tracheal disruption was to establish and maintain a patent airway to provide sufficient tissue oxygen delivery and then there was assessment of patient condition and acute problems. Surgical procedures were: tracheal resection and anastomosis for tracheal disruption (8 patients) and laryngeal repair for laryngeal injuries (2 patients). Five patients were treated immediately (few hours to 4 days post injury) and others were treated with a delay of 57 to 730 days. Patients were followed up post-operatively for the development of immediate and delayed complications. The average time between the accident and the surgery was 154. 6 days (between a few hours to 370 days). The follow up was carried out for a minimum period of 12 months to a maximum period of 84 months. Eight patients had bilateral vocal cord paralysis before operation. After the surgery 2 cases resumed improved vocal cord function، 2 patients sustained unilateral vocal cord paralysis and in 4 patients vocal cords sustained bilateral paralysis but were in paramedian position. All patients were decannulated finally. In spite of vocal cord paralysis in most of patients، tracheal resection and anastomosis، without tracheotomy، was possible in all cases. With proper treatment، it is possible for all patients to be decannulated with patent airway and acceptable voice.

Video-assisted thoracoscopic surgery (VÂTS) has been developed as a minimally invasive alternative approach for various diagnostic and therapeutic thoracic operations that previously required open thoracotomy. Postoperative pain is less after VÂTS than after conventional thoracic surgery، but is still significant. The purpose of this randomized double blind clinical trial was to compare the effect of interpleural morphine analgesia with traditional intravenous morphine administration on pain and supplemental analgesic usage after VÂTS.

30 Âmerican Society of Ânesthesiologists classes Ï and ÏÏ patients who had VÂTS under general anesthesia were randomly divided into two equal groups. Ât the completion of operation، a catheter was placed in the pleural space under thoracoscopic vision. Patients received a single bolus of 0. 1 mg·kg-1 of morphine either interpleurally or intravenously. During the first postoperative 8 hours، pain score at rest and on coughing، supplemental analgesic requirements، mean arterial pressure، heart rate، arterial blood oxygen saturation، degree of sedation، and side effects were monitored every one hour. The pain severity was evaluated by visual analogue pain scales (VÂS، 0-10).

No statistically significant difference was observed between the groups in relation to pain intensity، hemodynamic variables، or side effects during study period. Çonclusion: Ïnterpleural morphine did not provide superior analgesia compared with intravenous morphine after thoracoscopic surgery.

Introduction & Thymoma is not a common tumor, but is one of the most common mediastinal neoplasms. Treatment strategies for different kinds of thymomas are controversial. In Iran few studies have been reported on this matter. Demography, clinical course, histopathology and progression free survivals (PFS) of 53 patients with thymoma were investigated retrospectively. Data analysis was done with Kaplan - Meyer method. Survival rate has been described according to PFS (survival between diagnosis and recurrence or death). Using log-Rank test, the difference between two groups of patients with invasive tumor and non-invasive tumor was studied. Patients were 32 male and 21 female with mean age of 43 years (17-75 years). The most common symptoms were: cough (43.4%), dyspnea (39.6%), myastnenia (20.8%), weight loss (18.9%), and chest pain (17%). Most of tumors were in advanced stages. Treatment modalities were: surgery in 20.8%, surgery and chemoradiation in 66.8% and chemotherapy alone in 7.5% cases PFS results were 5.75 + 2.45 years. PFS between patients with invasive tumor and patients with non-invasive tumor did not show meaningful difference (P=0.616). In Iran, no definite protocol for therapy of thymoma has been recommended. Different modalities are used in our country. Although the principle method of treatment is surgery, other treatment modalities are used as well. Considering the slow growing pattern of this tumor, evaluation of different treatment modalities, need a prolonged follow up.

Fee splitting (FS) is return of a portion of treatment fees for referring patients to practitioners or healthcare centers and is a practice, which is seen, more or less in our medical profession. Although Fee splitting has been noticed and criticized in international publications and medical associations, it seems to be overlooked in our national society of medical practice. Foreign medical literature and attitude of medical societies towards FS as well as legal aspects of this issue were studied. Then the analysis was presented through results and discussion. Reliable medical literature and attitude of most of medical societies are not only in strong opposition to FS but also this issue is considered immoral and illegal in their view. In most of the countries some codified law has been formulated against FS. Some renowned authorities of medical profession have strongly opposed to FS. Also it has been remarkably emphasized that charging patients is permitted only for direct medical services. Although different types of FS are seen in our medical society, unfortunately or national medical societies have taken no practical action in this regard. FS is totally against patients ‘rights and medical profession and leads to destruction of ethical practice of medicine and prevention of scientific-ethical development of medical society. Therefore, medical societies are primarily responsible to take practical measures and provide educational services for medical students and residents.

Introduction & Management of post intubation tracheal stenosis in patients with cardiac problems hasnt been considered as a separate item. In this study, we tried to investigate this problem and to find the potential differences in this group. In a retrospective study of patients with post intubation tracheal stenosis, treated between 1994-2008 at Masih Daneshvari Hospital, results were compared between two groups, study group (a group of cardiac patients with primary heart diseases or history of cardiac surgeries), and all other patients (control group). Patients in the study group had a higher mean age than the control group, but the results of treatment were similar in both groups. However, the response to the non surgical methods was better in the study group. The presence of cardiac problems in the patients with post intubation tracheal stenosis shouldnt affect our decisions for the treatment of these patients. Tracheal resection and anastomosis isnt considered a highly stressful operation in these patients. -------------------------------------------------------------------------------- Article KeyWords: