فهرست مطالب shadmehr mb

Tracheal stenosis is still a serious consequence of endotracheal intubation. Previous classification systems are commonly descriptive and are not intended to deal with management approach. The aim of this study was to present a classification system for post intubation tracheal stenosis and evaluate its efficacy in distinguishing critically ill patients who need surgical intervention. This classification system was developed based on size and type of stenosis and associated clinical signs and symptoms. Stenosis was graded based on the results of clinical examination and rigid bronchoscopy. All patients received surgical or conservative treatment based on the judgment of a surgeon experienced in management of post-intubation tracheal stenosis without considering their score. ROC curve analysis was done and cut-off point was established based on the greatest Youden index. Sixty patients were studied. Resection and anastomosis were done for 49 patients. The mean score for all samples was 9.18 (range 8.77-9.45). Chosen cutoff point was 8.5 and calculated sensitivity and specificity were 89% and 42%, respectively. Positive and negative predictive values were 83.7% and 54.5%, respectively. A reasonable agreement between the estimated score and surgeon’s clinical judgment (kappa=0.78) was observed. A statistically significant relationship was observed between scores greater than 8.5 and need for surgical intervention (P= 0.007). We presented a scoring system for post-intubation and tracheostomy tracheal stenosis using main factors influencing diagnosis and treatment and its efficacy was evaluated prospectively. It seems that this system would be capable of assimilating the treatment interventions and comparing them.

Incidence of post-intubation tracheal stenoses is relatively high in Iran and the majority of tracheal surgeries are performed to treat these strictures. Therefore, it is important to become familiar with the nature of tracheal stenoses and know their treatment methods. Most surgeons learn different methods of tracheal surgery through operating on cases of post-intubation tracheal stenoses and apply these methods for surgical operation of tracheal tumors. We mainly focused on the technique of tracheal surgery, patient selection, and pre-op and post-op equipments required. Other related fields such as anatomy of the trachea, bronchoscopy, imaging, laser therapy and stenting are mentioned when necessary.

Hydatid disease, still endemic in developing countries, involves the liver and the lungs of the vast majority of cases. We report a very rare presentation of hydatid disease in a 35 year-old man with a cervicomediastinal mass and vocal cord paralysis, suspected of thyroid tumor. Surgery was curative and dysphonia disappeared completely.

Due to the diversity of surgical techniques and great differences in the incidence of pulmonary hydatid cysts around the world, the most appropriate surgical technique has not yet been substantiated. We presented the results of a single surgical technique in a consecutive group of patients and described the technical details.Methods and Materials: The study was conducted during an 8-year period on 125 patients with a mean age of 33.1 yrs that were suffering from pulmonary hydatid cysts. The surgical procedure included: thoracotomy, opening the cyst, removing all its contents, removal and suturing the bronchial openings. The pericyst cavity left open into the pleural space. Surgical complications, morbidity and mortality rates were evaluated. In addition, the recurrence rate was assessed post-operatively by periodic chest radiographs. There were a total of 181 cysts in 125 patients; 156(86.2%) cysts were operated via the above-mentioned technique and for 25 cysts due to destruction of parenchyma, lobectomy (n=9) or segmentectomy (n=2) was performed. Complications included prolonged air leakage in 4, persistent pleural effusion in 1 and pulmonary embolism in 1patient. There were five recurrences (2.8%) and 1 death due to pneumonia and sepsis. Thoracotomy, evacuation of the endocyst and closure of the bronchial openings comprise an appropriate surgical technique for the treatment of hydatid cysts of)

Although presence of pulmonary metastasis is indicative of disease progression and its untreatable nature, in recent decades, numerous efforts have been made for treatment of these patients by surgical resection of metastatic lesions. The efficacy of this procedure has been variable in various reports and different diseases. This study aimed to evaluate the effect of metastatectomy in survival rate of patients with pulmonary metastases who underwent metastatectomy in Masih Daneshvari hospital. This was a retrospective study and we evaluated medical records of 99 patients suffering pulmonary metastasis who had been referred to our center during 1995-2007; out of which 48 patients who were qualified for metastatectomy underwent this operation. The required qualifications for surgery included: feasibility of resecting all metastatic lesions, tolerance of surgery by the patient, absence of metastatic lesions in organs other than the lungs, and control of primary disease. Information regarding the site of primary lesion and its pathology, time interval between the diagnosis of primary disease and metastasis, surgical morbidity and mortality, form of surgical procedure, type of incision, number of pulmonary metastases and survival rate of patients was collected. Patients were followed up via clinical visits. In case of insufficient clinical visits, we contacted the patient or his/her family and collected the rewired data. Obtained data were analyzed using SPSS software. To assess the patients'' survival rate after the operation, Kaplan-Meier test was used. Sixty-seven pulmonary metastatectomies were conducted on 48 patients (31 males and 17 females) in the age range of 16-86 years (mean 40 yrs). Twenty-five patients had unilateral and 23 had bilateral metastases. Among patients with bilateral metastases, 7 underwent single-phase metastatectomy while 16 underwent two or multi-phase metastatectomy. Surgical incisions were done through the following approaches: in 60 cases through postero-lateral thoracotomy, in 4 cases through mid-sternotomy and in 3 cases through bilateral anterior-transverse thoracotomy along with sternotomy (clamshell). In 61 cases pulmonary metastatic lesion was removed by wedge resection, in 14 cases by lobectomy and in one case by pneumonectomy. Mean number of resected lesions was 6.7 (range 1 to 59). Post-operative complications occurred in 10 patients (15%) including pneumothorax in 9 cases and chylothorax in one. No morbidity, mortality or life-threatening complications occurred in any of the patients. The mean survival of patients following metastatectomy was 22 months (range 1 to 128 months) and their 5-year survival was 24.5% five patients had 5 years (60 months) or more survival. Although the under-study population was not homogenous pathologically, it seems that metastatectomy with acceptable morbidity, increases the survival of patients and in some cases results in their complete recovery.

Bronchial carcinoids are rare, slow growing neoplasms with nonspecific clinical signs which can mimic many respiratory syndromes. To evaluate clinical presentations, diagnosis and modes of treatment of these tumors in long term, a clinical research was performed in our center. The aim of this presentation is to report our experience.

By completing the prepared computerized data sheets for these patients and use of SPSS and Access softwares and Fisher exact and Mc Nemar tests, informations about age, sex, clinical signs, Hx of smoking, diagnosis and the results were evaluated. The evaluation took eleven years (1996-2007) therapies, with a complete follow up in 86.4% of the patients.

73 patients (38 women, 35 men) with mean age 41.4 years-old (range 11-70) were treated, with diagnosis of bronchial carcinoids. Surgical resections (from wedge resection to pneumonectomy) with or without mediastinal lymph node dissection (MLND) were performed. Other therapies such as bronchoscopic resections or ND YAG laser ablation were done before surgery in some patients. There were two recurrences both in lymphatics (2.7%). During this period 6 patient's (8.2%) have been died, 4 from operated patients (%6 of total operated ones) and one due to surgical complication and 2 were among non-operated ones (28.6% of non-operated cases).

Bronchial carcinoids with slow progression are often treated as other diagnoses before definite diagnosis. Fiberoptic bronchoscopy is more accurate in their findings than rigid broncoscopy (P= 0.04), were as considering that rigid bronchoscope should be available during biopsy time due to the high risk of hemorrhage. Their treatment is surgical resection (maintaining as much paranchyma as possible) with mediastinal lymph node dissection especially in atypical ones. Local recurrence was in lymphatics in our patients. When possible, re-resection is the treatment of choice for recurrences. The use of endoscopic resection or laser ablation in finding tumoral origin or in treating obstruction and infection distal to it might be helpful. Role of chemotherapy and radiation aren't clearly obvious.

A few number of post-intubation tracheal stenosis recur following resection and anastomosis. Several factors appear to be responsible for recurrence but there is insufficient data available in this regard. In this study we assessed the factors responsible for the recurrence of post-intubation tracheal stenosis after resection and anastomosis in a large group of patients who were operated in our center by one surgical team.

All patients who underwent tracheal and/or subglottic resection and anastomosis due to post intubation tracheal stenosis, at our center during 1995-2006 were divided into two groups (case and control). The study group consisted of patients who had developed recurrence while the controls had no recurrence. The diagnosis of the recurrence was made based on the presence of clinical signs or symptoms and bronchoscopic confirmation. The following variables were compared in both groups: Age, sex, duration of intubation, the reason for intubation, period of time between intubation and surgical operation, history of previous tracheotomy, previous therapeutic interventions such as laser therapy, subglottic involvement, length of resection, presence of tension at the site of anastomosis and the development of surgical site infection. This was a case - control study and statistical analyses were performed using SPSS 15.

Four hundred ninety-four patients underwent resection and anastomosis (365 women and 129 men) with a mean age of 25-34 years (in the range of 4 months to 83 yrs.). Fifty-two patients (10.5%) developed recurrence. Length of resection (mean 42.8 mm in the case group versus 37.8 mm in the control group; P=0.012), the presence of tension at the site of anastomosis (32.7% versus 19.3%; P=0.03), the development of infection at the site of operation (18.2% versus 5%, P=0.006) and subglottic involvement (36.5% versus 19.2%, P=0.005) were higher in the case group and it seems that these factors are responsible for the recurrence.

In this study, the factors responsible for increasing the recurrence rate of post- intubation tracheal stenoses were long lengths of resection, presence of too much tension at the site of anastomosis, wound infection and subglottic involvement. We believe that the surgeon can play an important role by decreasing tension, preventing infection, and preserving subglottic structures.

The field of thoracic surgery is a postgraduate sub-specialty of general surgery and has developed considerably in Iran during the recent decades. Nowadays, thoracic surgery procedures are performed by specialists who have been trained specifically in this field and the quality of care given is in line with international standards. This paper addresses the history of thoracic surgery in Iran.Data were collected through interview of professors, review of archives and personal albums and data present in the council of medical education. Almost 80 years ago, general surgeons used to perform thoracic surgical procedures. But closed-circuit anesthesia was not prevalent in Iran until 1940 and there was no training available in the country for thoracic surgeons. Antibiotics were not available and surgeons were not acquainted with new methods to evacuate the pleural space (chest tube and under water seal drainage). The only procedures performed were limited to management of emergencies, trauma and abscess drainage. Surgical intervention for treatment of tuberculosis in some patients was one of the factors responsible for development of this field of surgery.General surgeons trained abroad that came back to Iran were familiar with the principles of thoracic surgery and would perform it. In some army medical centers and some centers affiliated to foreign countries, thoracic surgeries were performed by Iranian or foreign physicians. Professor Yahya Adl used to perform thoracic surgeries and taught it to his residents. In 1951, Dr. Sadegh Ghazi and shortly after, Dr. Anwar Shakki started operations in Bou-Ali and Abo-Hossein Hospitals at the request of the TB charity foundation. They were the pioneers who started to perform TB, lung and thoracic surgeries. They were educated in France. The period of 1951-1961 can be considered as the initiation period of thoracic surgery as a subspecialty in Iran. Afterwards, this field was extended to the Masih Daneshvari, Sorkheh Hesar and army medical centers. In early 1950, cardiac and vascular surgeon graduates from the USA and other countries who had returned home established the field of thoracic surgery at Tehran University and other universities. Thus, official training in this field was started. In 1984, thoracic surgery became a postgraduate sub- specialty field approved by the medical education council. Thus far, over 80 physicians have graduated in this field most of which are working in academic fields throughout the country. Tehran, Shaheed Beheshti and Tabriz Universities of Medical Sciences have departments approved for training thoracic surgery fellows. In many universities and several medical centers, trained surgeons have established thoracic surgery wards and are working in this field. (Tanaffos 2007; 6(2): 80-91)

Hydatid disease is caused by an infection with the cestode, Echinococcus granulosus and is endmic in Iran. Medical therapy and surgical management are two main treatments. The purpose of this study is to represent our ten-year experience in surgical management of patients with complicated pulmonary hydatid disease including cysts ruptured into the pleural space or bronchi, multiplicity, hemoptysis, large size cysts and coexistence with liver cysts. Medical records of 109 patients, who underwent surgery for the treatment of pulmonary hydatid disease in Masih Daneshvari Hospital from December 1995 to October 2005, were reviewed. Among these patients, we selected our study group in accordance with the following criteria:1) Cyst rupture into the pleural space or bronchi, 2) Occupying more than two third of the hemithorax in radiological studies, 3) Multiple cysts, 4) Massive hemoptysis, and 5) Synchronous pulmonary and liver cysts. Among the 109 patients with pulmonary hydatid cyst, 82 patients (59% male and 41% female) met the above mentioned criteria. The mean age of patients was 31.7 years (range 9-80 yrs). The cyst diameter was determined by radiological imaging. The mean diameter was 6.23 cm, and 13 patients had giant cysts (occupying more than 2/3 width of the hemithorax). In this study group 55 patients had ruptured hydatid cysts, 29 had multiple cysts, 11 had significant hemoptysis and 15 had synchronous pulmonary and liver cysts. All patients had undergone surgery with or without previous medical therapy. Our procedure of choice was thoracotomy, cystectomy and closure of the bronchial openings before irrigating the cavity with silver nitrate (0.5 %) soaked sponge. Pulmonary resection was done in 8 patients due to the irreversible parenchymal damage. Post operative complications occurred in 16 (19%) patients including residual pleural space in 8, broncho-pleural fistula in 2, pleural effusion in 1, pulmonary embolism in 1, osteomyelitis of sternum in 1, laceration of diaphragm in 1, and inability to access the liver hydatid cyst after thoracotomy and post operative pulmonary insufficiency necessitating mechanical ventilation also in 1 patient. One patient died because of sepsis (she had been operated on for combined pulmonary and liver hydatid disease). In the 1 to 60 months follow up period, 2 recurrences occurred. Although post operative complications occurred in 19% of our patients, all were treated by conservative managements. This rate of complications was acceptable among patients with complicated hydatid disease. Our procedure of choice is draining the cyst; closing all the bronchial openings in the pericyst and leaving the pericyst cavity open into the pleural space. (Tanaffos 2007; 6(1): 19-22)

The esophageal perforation can be fatal unless diagnosed promptly and treated effectively. The high mortality rate related to delayed treatment is due to an inability to effectively close the perforation site to prevent leakage and ongoing sepsis. This study was performed on patients who were referred to three hospitals of Shaheed Beheshti and Tehran Universities of Medical Sciences during two years. All patients admitted in these hospitals with esophageal perforation lasting for more than 24 hours were studied. There were 24 patients (12 males, 12 females) with the mean age of 37.5 yrs. The most frequent symptoms and signs were: Chest and abdominal pain in 11 cases (45.83%), empyema in 11 cases (45.83%), fever in 10 cases (41.66%), pleural effusion in 8 cases (33.33%) and emphysema in 3 cases (12.5%). The most common causes of esophageal perforation were use of devices during esophagoscopy and foreign bodies in 13 cases (54.17%), iatrogenic trauma in 4 cases (16.67%), Boerhaave''s syndrome in 4 cases (16.67%), ingestion of burning chemicals in 2 cases (8.33%) and esophageal cancer in 1 case (4.17%).Four (16.66%) of all patients died while others were discharged with no significant complication in long time. This study was performed on patients referred to university hospitals; therefore, the results are different from those of community. Most of the perforations were due to intraoperative negligence or device manipulation. The outcomes of the whole procedures were good concluding that late diagnosed esophageal perforations can be managed surgically with good results but with a longer period of hospitalization. (Tanaffos 2006; 5(1):51-57)

Air-leak is of the common complications of pulmonary resection, yet there is no consensus on its management. Some authors are in the belief that if, after surgery the lung can remain open, absence of suction will quickly stop the air-leak from the chest tube, whereas others believe that using the suction is essential. This study aims to evaluate the role of chest tube suction after surgery. This is a randomized clinical trial performed on 31 patients who underwent different lung surgeries. After surgery, chest tubes of all patients was connected to the suction till the next morning. Afterwards suction was discontinued for 3 hours and chest radiography was obtained. In presence of pneumothorax in chest-x-ray or in cases of air- leakage from the chest tube, use or no use of chest tube suction was determined randomly. In 13 out of 31 patients, chest tube suction was used. In these patients, adding the suction had no effect on shortening the duration of air-leak or hospital stay. We also tried to evaluate the probable effective causes of air-leak in these patients. In this regard we did not find any relation between the age, FEV1 and PaO2 before the operation with air- leakage after the surgery. But there was a significant correlation between the rate of air-leakage and PaCO2 before the surgery. Risk of air-leakage on the 7th day after surgery was greater in those patients in whom the degree of air-leakage was higher on the first day. Use of chest tube suction had no effect on controlling the air-leakage. In this study, use of chest tube suction had no effect on shortening the air- leak period after surgery. In our patients, PaCO2 was an important factor in predicting the risk of air-leak from the chest tube. (Tanaffos 2006; 5(1): 37-43)

A 73 year- old man with cough, dyspnea, generalized lymphadenopathy and left sided pleural effusion was admitted with primary impression of lymphoproliferative disorders. The precise evaluation showed systemic primary amyloidosis with the rare presentation of generalized lymphadenopathy and massive pleural effusion without any other organ involvement as the available tests showed. (Tanaffos 2005; 4(16): 69-71)

The incidence of suicide attempt has been increasing in recent years. Presenting a group of patients who attempted suicide, underwent ventilatory support and developed postintubation airway stenosis (PIAS) may help us in prevention and better understanding of this complication. Among patients who referred to our center for treatment of PIAS, those who had been intubated for suicide attempt were investigated in a prospective study. Information was entered in a questionnaire and regular follow ups were done in a 15-month period (April 2003 to July 2004). Among 100 patients with PIAS, 19 enrolled in this study including10 females and 9 males (mean (±SD) age, 25.3 (±9.96) yrs; ranging from 17 to 56 yrs). Type of disease and reasons of suicide were categorized by a psychologist as follows: Eleven patients with psychosocial stress along with an immature personality back-ground, 7cases of psychological disorders and one with an unknown cause.Direct causes of committing suicide included family problems in 10 cases, lovesick in 2, addiction in 3, depression in 6 and social problems in 2 cases (some patients mentioned two reasons and one refused to mention the reason).Mean time of intubation was 14.78 days (3-30 days), and the mean length of stenosis was 35.12 mm (20-50 mm), 8 patients underwent tracheostomy. Three patients were treated with bronchoscopic dilation and 16 underwent laryngotracheal resection and reconstruction. There were 8 cases of recurrence after resection among which 4 were treated by second resection, 2 recovered by bronchoscopic dilation and 2 managed by stenting. This group of patients (study group) was compared with a similar group of patients in whom the causes of intubations were different (control group). Incidence of post- surgical recurrence (p=0.011) and the length of stenosis (p=0.01) were higher in the study group. In our patients, social problems such as unemployment, illiteracy and singleness were the more frequent causes of suicide compared with psychological disorders. Patients who undergo mechanical ventilation due to suicide and develop PIAS could be treated by tracheal resection and reconstruction; although the incidence of post- surgical recurrence is higher in them compared with the other groups of patients with PIAS. (Tanaffos 2005; 4(15): 11-16)

The cause of pleural effusion in some patients can not be found even after biochemical, bacteriologic and cytological examinations of the pleural fluid and closed needle biopsy of the pleura. In this group of patients the next diagnostic step would be an open pleural biopsy through a limited thoracotomy or video-assisted thoracoscopic surgery (VATS), the latter procedure has replaced the former in many centers due to its advantages. In order to evaluate these advantages, 59 patients with undiagnosed pleural effusion were operated on through either limited thoracotomy or thoracoscopy form April 1998 to September 2000, in a prospective clinical trial. There were 40 males and 19 females in the age range of 10 to 89 yrs. There was no significant statistical difference between the two groups in terms of sex and age. There was no statistical difference between the two groups in terms of diagnostic accuracy, postoperative pain, hospitalization, morbidity and mortality. Based on these results and minimal scar, VATS is a safe diagnostic procedure in this group of patients replacing limited thoracotomy.)

Hydatid disease is the most common serious infection in human beings caused by cestods and Iran is one of the endemic regions of this infection. This research has been performed to evaluate and analyze the cyst location, its diagnosis and treatment This descriptive study was performed on the patients suffering from hydatid infection who were admitted in the pediatric department of Massih Daneshvari Hospital from March 1996 to April 2004. Data in regard to age, sex, clinical signs and symptoms, radiographic findings (location and number of cysts) and type of treatment (medical or surgical) were collected and analyzed statistically. A total of 11 patients suffering from hydatid cyst were evaluated in this study. Among these, 10 were male and 1 was female. Age range of patients was between 0 to 16 years of age and the mean age was 13 years. The results of this study show that pulmonary hydatid cyst in children is more common in boys.Cough (100%), sputum (100%), and hemoptysis (54.5%) were the most common symptoms. Chest x-ray and lung CT scan were obtained in all patients. CT scan diagnosed hydatid disease in 100% of the patients. Common locations of the cyst were in the lower lobes of both lungs in 81% of the patients while in 54% it was in the lower lobe of the left lung. In 2 patients we found hydatid cyst in both lung and liver. Surgical treatment was performed in all 100% of the patients. Among these, one patient underwent pulmonary lobectomy while in the remaining 10, surgical approach with evacuation of the cyst was performed. Hydatid disease is hyperendemic in Iran, and usually patients do not seek medical advice on time. It causes high mortality in patients even with proper treatment along with high costs of management. Therefore, it is necessary for the authorities and researchers to pay more attention in this regard. In this survey, CT scan was the best and the most definitive method of diagnosis and surgical treatment along with evacuation of the cyst was the selective method of treatment in 90% of the patients in this study.

During upper mediastinal surgical interventions, innominate vessels may be ruptured inadvertently or divided intentionally by the surgeon for a better exposure. The question, whether a divided innominate artery or vein should be reconstructed or not, has not yet been clearly answered. In a retrospective study, 11 patients who underwent surgery between 1996 and 2004 in our department (7 females & 4 males) with mean age of 38.7 years old were found undergoing an upper mediastinal surgery with ligation of a great vessel.Fourteen great vessels (6 innominate arteries, 4 left innominate veins, 3 right innominate veins and one right carotid artery) were ligated with no reconstruction.The vessels were intentionally divided for a better exposure or ligated for controlling of severe bleeding (due to an iatrogenic trauma) in 6 and 5 patients, respectively. One patient with innominate artery and right innominate vein division suffered from a 48 - hour period of coma due to a cerebral edema which was completely resolved. Two patients developed infection at the site of sternotomy and were managed with antibiotics and wound care. No complication occurred in the remaining. In two cases with division of innominate arteries, the peripheral pulses disappeared, but there was no muscle weakness, or ischemic pain in the limb. The follow-up period was between 2-96 months (mean; 24.8). In critical condition and when surgical situation is not suitable for reconstruction, innominate vessels could be safely ligated and divided for a better surgical exposure and control of bleeding; with acceptable post-op risks.

The first surgical resection of single lung metastases was reported by Weinlechner in 1882. This metastatectomy was done for a discrete pulmonary metastases which was discovered during resection of a chest wall sarcoma (1). The patient died on the first day after surgery. One year later, Kronlein performed same operation successfully (2). During surgery of a recurrent sarcoma of the chest wall in an 18-year-old girl, he noticed a pulmonary metastases in the size of a walnut. He removed it with a wedge resection and the patient survived for 7 years later but unfortunately died due to a second recurrence. In spite of this successful metastatectomy, there was a long period of suspicion about metastatectomy among physicans. It was considered that the presence of metastasis indicates spreading of the disease so that, surgery is not useful. In spite of this belief, many efforts were done for surgical treatment of patients with pulmonary metastases (3,4). The advent of chemotherapy during 1960-70 caused an important impact on the treatment of pulmonary metastases. The majority of patients suffering from different malignancies survived for a longer period of time by this method, and some of them referred with solitary and removable pulmonary metastasis. In addition, the surgical methods were improved, and postoperative mortality was decreased.Nowadays, pulmonary metastasectomy is a part of treatment in most malignancies, and controversies are only with regard to operation indication and selection of patients. This procedure had good results in numerous reports (5-10). Nevertheless, the total cure rate is around 20%, and successful results have been reported mainly in selected patient groups. Thus, we do not recommend metastasectomy as a routine procedure in all patients who have metastases. With good selection of patients and surgical approaches, nearly one third of all patients presenting with pulmonary metastases as the only site of the disease may benefit from resection of their metastases. (Tanaffos 2003; 2(6): 7-24)

Management of the airway stenosis due to Wegener’s Granulomatosis Disease (WGD) is controversial. A 37-year-old woman with WGD and severe subglottic stenosis was treated successfully by resection and anastomosis of the subglottic area. Twelve months after the operation, she enjoys normal breathing and near normal voice. (Tanaffos 2002; 1(4): 73-76)