Role of Thoracic Sonographic Scan in Diagnosis of Pneumothorax

Background: Pneumothorax is a common problem seen in patients with acute and chronic medical and traumatic conditions with wide range of clinical presentations ranging from subtle decrease in breath sounds to cardiopulmonary arrest caused by tension pneumothorax. Pneumothorax is traditionally diagnosed by chest radiography, ultrasound is fairly a new modality of diagnosis. Ultrasound is a rapid noninvasive bedside test that may reduce mortality from this pathology by early detection. There are certain sonographic criteria that can exclude or confirm pneumothorax;this work has been performed to analyze these criteria. Patients and Methods: The study was done in Sulaimani teaching hospital and Sulaimani emergency hospital from June 1st to 10th August 2013. We performed thoracic ultrasound on fifty three diagnosed cases of pneumothorax (by chest X-ray &/or thoracic computed tomography). The age of the patients ranged between (10 - 82 years), mean age (38 years), 35 males and 18 females. Lung sliding sign, lung point sign and A line signs were recorded and analyzed. Results: The sensitivity, specificity, positive predictive value and negative predictive values of absent lung sliding sign were: 100%, 94%, 94% and 100% respectively, for lung point sign were: 70%, 100%, 100% and 68% respectively, for A line sign were: 91%, 71%, 73% and 91% respectively, for absent lung sliding and lung point sign together were 70%, 100%, 100% & 68.9% respectively. Conclusion: We confirmed the conclusion of other studies which stated that presence of lung sliding excludes pneumothorax and identification of lung point in a case with absent lung sliding is diagnostic of pneumothorax.

Heparin versus Saline Solution for Locking of Totally Implantable Venous Access Port (TIVAP): Cohort Study of the First Kurdistan Series of TIVAP

Introduction: Totally implantable venous access port (TIVAP) is essential prerequisite for most of chemotherapy protocols. Flushing with 0.9% sodium chloride becomes an alternative to heparinized solution. As flushing and locking solutions are still controversial, this study was conducted to compare efficacy of heparinized solution versus normal saline solution for locking in ports TIVAP. Patients and Methods: Prospective Cohort study performed in teaching hospital Sulaymaniyah-University of Kurdistan, Iraq, including 384 TIVAP implanted in cancer and non-cancer patients. The study reports the TIVAP outcome in 2 groups of patients where 2 different solutions used for maintaining catheter’s patency by heparinized solution in group (A), versus normal saline for group (B). Results: In group A, the rate of complications was 8.2% (n = 16) while in group B complications rate was 7.9% (n = 15). Thrombosis in group A occurred in 1.03% of the cases and in group B was 1.57%. There were no significant differences between the two groups regarding the causes for unwanted removals of the TIVAP. Conclusions: The results of our study suggest that heparin has no role in preventing the early or late complications of TIVAP and we do not recommend using it as a locking solution.

Vascular Trauma Registry Analysis in Sulaimani Province of Southern Kurdistan

Background: Vascular injury presents a great challenge to the trauma and vascular surgeons because it needs urgent diagnosis and intervention. Aims: Prospective cohort study is to determine management and outcome of peripheral vascular injuries in a tertiary centre with very poor facilities. Methods: Analysis of peripheral vascular injuries during August 2013 to August 2014. Results: Total of 47 patients (3.4%) from 1377 total trauma admissions had vascular injuries. Penetrating trauma was present in 93.6% of cases. Brachial artery injury was the highest (31.9%), followed by superficial femoral and popliteal arteries (each with 17% incidence). Vein injury occurred in 61.7% of cases. End-to-end anastomosis performed in 76.6% of cases;arterial ligation was done in 14.9% of cases;venous graft was harvested in 6.4% of cases;and arterial wall was repaired in 2.1% of cases. Conclusions: Early intervention is the most important determinant factor of outcome.

What Is the Best Surgical Approach for Bilateral Pulmonary Hydatid Cysts in Children?

Introduction: The most common site for hydatid cysts in children is the lungs while in adult hepatic cysts are predominant. Bilateral pulmonary involvement is relatively rare and its surgical management is poorly described in the current literature. Until now no definite consensus has been described in the literature for the ideal surgical approach in pediatric bilateral pulmonary hydatid cysts (BPHC). The aim of this prospective cohort study was to describe the problems encountered in treating pediatric BPHC by two different surgical techniques. Patients and Methods: Between June 2007 and June 2014, 60 children (group one = 31, group two = 29) with BPHC were operated on in our center. Group one included all children with BPHC operated by single session bilateral anterolateral mini-thoracotomy. Group two included all cases operated by two stage standard posterolateral thoracotomy at 21 days interval. Results: In group one (19 males and 12 females), the mean age was 8.9 years (3.5-17). In group two, there were 29 cases (18 males and 11 females), the mean age was 9.6 years (2-17). There was no significant statistical difference in terms of the presentations and age distribution. The duration of surgery in group one was significantly shorter and the duration of hospital stay was significantly shorter as well (group one 3.6 days versus 4.6 days in the second group). Pain scale was not more in the first group as it was believed to be. Conclusion: We believe that single session bilateral anterolateral thoracotomy is a better approach than either one stage successive thoracotomies, median sternotomy or clamshell thoracotomy as it involves less postoperative pain and does not precipitate a decrease in the respiratory capacity.

Esophageal Perforation in Children: Experience in Kurdistan Center for Gastroenterology and Hepatology/Iraq

Background: Esophageal perforation is a rare, but potentially life threatening injury. The etiology and management of this condition have changed overtime. Iatrogenic causes are increasingly recognized and management is evolving towards more conservative approaches. Objective: To review our experience in the management of esophageal perforation in pediatric patients. Patients and methods: This retrospective study was conducted in the Kurdistan center for gastroenterology and hepatology in Sulaimani city. Review of records for cases of esophageal perforation during the period from January 2006 to October 2013 was performed. Results: Ten cases were found to have esophageal perforation. The causes of esophageal perforation were complications of endoscopic dilation for esophageal stricture (n = 7), button battery ingestion (n = 2), complication of esophagoscopy for corrosive injury (n = 1). The mean age was 42 months (range, 18 - 75 months). The diagnosis was made during the procedure in 6 cases, within 12 hours in 2 cases and late in the two cases of battery ingestion. Subcutaneous emphysema and respiratory distress were the main presenting features. The location of perforation was thoracic in 9 cases and cervical in 1 case. Conservative management was successful in 7 patients and surgical closure was done in two patients. One death has been reported. Conclusion: Iatrogenic causes were the most common causes of esophageal perforation. Conservative management with interventions guided by clinical response can have a favorable outcome and may become the best initial treatment strategy in the future. Further larger scale studies are recommended to establish the best protocol for conservative management.

Pattern of Cardiac Trauma in Sulaimani Province of Southern Kurdistan: 5 Years’ Experience

Introduction: Cardiac injuries are one of the important causes of death in young population. With aggressive resuscitative therapy and emergency room thoracotomy, the salvage rate of these patients can reach 35%. In this case series the types of presentation, methods of resuscitation, surgical approaches, operative and postoperative outcomes are discussed. Patients and Methods: From January 2009 to January 2014 there were 3157 patients treated for thoracic injuries at Sulaimani university hospital, 14 patients had cardiac injuries. All admitted cases with central chest trauma were submitted to a thorough clinical examination, ECG and eFAST (extended Focused assessment with sonography for trauma) and/or transthoracic echocardiography. Results: Total of 14 cardiac injuries from 3157 causalities were identified, which is 0.44% of the total admissions. Male gender was predominant (85.7% vs. 14.28%) for females. Mechanism of injury was mostly penetrating (85.71%) among which stabs were majority (57.14%) while bullet and shrapnel each constituted (14.28%). Mean time of interval between the accident and our intervention was 2.96 hours. No diagnostic test was 100% specific and sensitive. Discussion: Cardiac injury regarded as a crucial injury because of its high fatality. It is reported that 10.3% of emergency surgical operations are thoracic type and about 1% of them are associated with cardiac injury. Although any penetrating injury to the thorax may injure the heart but those within the box are more suspicious. We conclude that cardiac trauma is a fatal injury but still if the facilities are available the mortality can be minimized.

Mediastinal Hydatid Cyst Mimicking Malignant Mediastinal Neurogenic Tumor

Hydatid disease is caused by Echinococcus granulosus parasite. It is an endemic disease;particularly in many Mediterranean countries. The liver and the lungs are most frequently involved. Bone involvement is reported in 1% - 2% of the cases and about 50% of those are seen in the spine. Herein we report a case of primary spinal extradural hydatid cyst that caused paraplegia due to compression of the dorsal spinal cord and was diagnosed initially as case of lumber prolapsed intervertebral disc. The cyst was only discovered when the patient had progressive paraplegia and the preoperative provisional diagnosis was posterior mediastinal neurogenic tumor causing destruction of the pedicle and lamina of the fifth thoracic vertebra. Fortunately, she regained near full power after surgical treatment of her spinal cyst.

Single-Port Bilateral Thoracscopic Dorsal Sympathectmy for Primary Hyperhidrosis:Long-Term Outcome

Background: Primary hyperhidrosis of the upper limbs is characterized by over activity of the eccrine sweat glands, primarily occurring on palmar, plantar and axillary regions. It is distressing and often socially disabling condition. Conservative treatment is usually not effective in controlling the disease mainly due to adverse effect of therapies. Endoscopic thoracic sympathectomy is considered as the treatment of choice, causing minimal morbidity and high success rates and patient satisfaction. Objective: The study aims to evaluate the long-term outcomes of single port bilateralthoracoscopic dorsal sympathectomyin treatment of primary hyperhidrosis of the palm and axilla. Methods: In this prospective study, performed primarily by a single surgeon, between August 1st 2010, and August 1st 2012, we performed 200 thoracoscopies on 100 patients with signs and symptoms of primary palmar and axillary hyperhidrosis in different age groups and in both genders, and all were studied and analyzed following treatment by single-port bilateral thoracoscopic dorsal sympathectomy in Sulaimani teaching hospital. Results: Total of 99 patients were satisfied with the outcome of post-surgery with a follow-up in the mean of 27 months and only one patient was reported no change in symptoms postoperatively. Complications reported in 6 patients inform of compensatory sweating (n = 2), Gestatory sweating (n = 1), Pneumothorax (n = 1), Intraoperative minor bleeding (n = 1) and only 1% failure rate was reported. No mortality was reported. Conclusions: Single port bilateral thoracoscopic thoracic sympathectomy is a very effective method in the management of primary hyperhidrosis. Single port provides less postoperative pain, safety, short operative time, and quick method for the treatment of primary hyperhidrosis in comparison to two or three ports approaches.

A Rare Retroperitoneal Mass:Leiomyosarcoma of the Inferior Vena Cava

Leiomyosarcoma of the inferior vena cava (IVC) is a rare soft tissue tumor, mesenchymal in origin that arises from smooth muscles of tunica media;it accounts for about 0.5% of all soft tissue sarcomas, and it is the commonest vascular leiomyosarcoma. The tumor progression is slow, and it is asymptomatic until advanced stage in which involvement of surrounding structures even when the symptoms present are nonspecific. Presentation of Case: A 60 years old lady presented with upper abdominal pain for 3 months duration. Past surgical history was significant for Hysterectomy 15 years ago. On examination: soft abdomen, palpable non pulsating right hypochondrial mass. Ultrasound of the abdomen showed tumor of the head of pancreas. CT scan showed large retroperitoneal tumor extending from the head of pancreas to IVC. Trans abdominal CT guided FNAC showed retroperitoneal sarcoma while Immunohistochemistry (IHC) was proved to be Leiomyosarcoma of the IVC. Discussion: Leiomyosarcoma of inferior vena cava (IVC) is a rare soft tissue tumor, mesenchymal in origin that arises from smooth muscles of tunica media;it accounts for about 0.5% of all soft tissue sarcomas, and it is the commonest vascular leiomyosarcoma. The type of surgical management is a matter of debate and includes resection alone, primary repair/cavoplasty, or replacement with a graft. Reconstruction of the IVC is not always required especially in chronic occlusions. Conclusion: Despite all the advanced modalities, surgery remains the most effective method for treatment of Leiomyosarcoma.