Left Tube Research Articles

Bilateral Pneumothoraces Following Central Venous Cannulation

We report the occurrence of a bilateral pneumothoraces after unilateral central venous catheterization of the right subclavian vein in a 70-year-old patient. The patient had no history of pulmonary or pleural disease and no history of cardiothoracic surgery. Two days earlier, she had a median laparotomy under general and epidural anaesthesia. Prior to the procedure, the patient was hemodynamically stable and her transcutaneous oxygen saturation was 97% in room air. We punctured the right pleural space before cannulation of the right subclavian vein. After the procedure, the patient slowly became hemodynamically instable with respiratory distress. A chest radiograph revealed a complete left-side pneumothorax and a mild right-side pneumothorax. The right-side pneumothorax became under tension after left chest tube insertion. The symptoms finally resolved after insertion of a right chest tube. After a diagnostic work-up, we suspect a congenital “Buffalo chests” explaining bilateral pneumothoraces and a secondary tension pneumothorax.

Bilateral pneumothorax, lung cavitations, and pleural empyema in a cocaine addict

A case of bilateral pneumothorax, lung cavitations, and pleural empyema in a cocaine user is described. The patient was treated by left tube thoracostomy and right lower lobectomy. The postoperative course was uneventful. Six months later, the patient remains asymptomatic. The pathology examination of the specimen revealed infected bronchiectasis, interstitial desquamative pneumonia, diffuse alveolar damage, subsegmental arterial thrombosis, and consequent areas of pulmonary infarction.

Pro: The New Bronchial Blockers Are Preferable to Double-Lumen Tubes for Lung Isolation

FOR MORE THAN HALF A CENTURY, the gold standard for achieving lung separation was and continues to be the use of a double-lumen tube (DLT). 1 Brodsky J.B. Lemmens H.J.M. Left double-lumen tubes: Clinical experience with 1,170 patients. Cardiothorac Vasc Anesth. 2003; 17: 289-298 Abstract Full Text Full Text PDF PubMed Scopus (139) Google Scholar However, anesthesiologists may face the need to use alternative methods to provide lung separation for the following reasons. First, DLTs are nonfriendly, bulky, and often difficult to insert and position. Second, the use of a DLT requires the need to change the tube to a single-lumen tube (SLT) if the patient requires postoperative ventilatory support. And, third, a patient's airway that is considered easy for insertion of a single-lumen tube may present a challenge for a DLT insertion.

A new genus and species of hermit crab of the family Paguridae (Crustacea: Anomura: Paguroidea) from the Vanuatu Archipelago

During a survey of the biodiversity of the southeastern part of Espiritu Santo, Vanuatu Archipelago, specimens of a tiny but distinctive new hermit crab species, referable to a new genus, were discovered in the shallow waters off the island. Herein, Pumilopagurus tuberculomanus new genus, new species, is described and illustrated. The genus is characterized by the development of a massive right cheliped, more than 0.7 total body length; male with a short left sexual tube directed from left to right across the ventral body surface and very short right sexual tube; and female with single left gonopore. Its relationship to other pagurid genera of comparable small body size is discussed.

Interstitial pregnancy in a woman with congenital afibrinogenemia

Without fibrinogen replacement, pregnancies in patients with congenital afibrinogenemia end in miscarriage between 6 and 8 weeks of gestation. Studies in animal models suggest that disturbance of the embryo's decidual attachment contributes to miscarriage in afibrinogenemia. Ectopic pregnancy in human congenital afibrinogenemia has not been previously documented. We present a case of right interstitial pregnancy in a woman with congenital afibrinogenemia, who had not received the recommended fibrinogen replacement for the first 6 weeks of pregnancy. The pregnancy followed a right salpingo-oophorectomy for ovarian hemorrhage. Therefore the embryo most likely entered the uterine cavity via the left tube only to move upstream into the lumen of the interstitial portion of the right tube. Our experience suggests that disturbance of the embryo's decidual attachment may have contributed to the development of an ectopic pregnancy. Therefore, fibrinogen replacement early in the first trimester is of utmost importance.

Can ultrasound be useful for predicting the size of a left double-lumen bronchial tube? Tracheal width as measured by ultrasonography versus computed tomography

Study Objective To correlate tracheal width as measured by ultrasound with width measured by computed tomography (CT), and to evaluate the possible role of ultrasound in the selection of the proper size of left-sided double-lumen endotracheal tubes (LDLTs). Design Two independent, prospective, observational clinical studies (Study 1 and Study 2). Setting University hospital. Patients Study 1 included 25 patients and Study 2 included 20 adult thoracic surgery patients who required a LDLT during anesthesia. Interventions and Measurements In Study 1, CT measurements of tracheal width were made at the coronary plane 0.5 cm above the sternoclavicular joint; CT measurements of the left main bronchus diameter were made 1 cm below the carina. Ultrasound measurement of tracheal width was performed just above the sternoclavicular joint in the transversal section. In Study 2, patients' tracheas were intubated with a LDLT based on ultrasound measurements. The frequencies of incorrect selections of LDLT and unsatisfactory lung collapse were analyzed. Main Results There was a strong correlation between tracheal width as measured by ultrasound and tracheal width ( r = 0.882, P < 0.001) and left main bronchus width ( r = 0.832, P < 0.001) as measured by CT. In 5 cases (25%), the incorrect LDLT by ultrasound was selected; and one (5%) was found to have an unsatisfactory lung collapse. Conclusion Measurement of the outer tracheal width by ultrasound can be a useful method for predicting the diameter of left main bronchus and for selecting a LDLT.

Unilateral twin tubal pregnancy successfully treated with methotrexate

Spontaneous twin ectopic pregnancy is extremely rare. Among more than 100 reported cases of twin tubal pregnancies, successful treatment with methotrexate has yet to be reported. A 26-year-old nulliparouswomanwas admittedwith vaginal bleeding and abdominal pain. She had previously undergone infertility treatment using ovulation induction with gonadotropins and intrauterine insemination. On admission, the patient's serum level of beta-human chorionic gonadotropin (β-hCG) was 763 IU/mL. Two gestational sacs were observed in the left tube on transvaginal ultrasound. An increase in serum β-hCG level was observed on the third day of hospitalization. A multiple-dose regimen of methotrexate (1 mg/kg of methotrexate on days 1, 3, 5, and 7, and 0.1 mg/kg of folinic acid on days 2, 4, 6, and 8) was begun when the patient's β-hCG serum level reached987 IU/mL.On day1 ofmethotrexate treatment, dilatation and curettage was performed and endometrium without chorionic villi was reported by the pathologist. Serum levels of β-hCG reached 1091 IU/mL on day 2, 1219 IU/mL on day 4, and 750 IU/mL on day 6. A single dose of methotrexate (1 mg/kg) was repeated on the 14th day as the serum level of β-hCG reached 1200 IU/mL. Serum β-hCG levels declined to within the normal range 32 days after initiation of the treatment. The main risk factors in this case are infertility treatment and smoking. Marcovici et al. [1] showed that conventional methotrexate treatment was unsuccessful for spontaneous bilateral tubal ectopic pregnancies, while hemodynamically stable unruptured tubal ectopic pregnancies and heterotopic pregnancies could be successfully treated with systemic methotrexate [2]. The present case reports a unilateral twin tubal ectopic pregnancy treated successfully using systemic multiple doses of methotrexate.

Unilateral triplet ectopic pregnancy after in vitro fertilization and embryo transfer

To present a case report of a unilateral triplet ectopic pregnancy (EP) conceived by IVF-embryo transfer. Case report. University Hospital, Budapest, Hungary. A 26-year-old infertile woman with a history of right salpingectomy, hyperprolactinemia, and male factor infertility underwent IVF-embryo transfer of three embryos. Early transvaginal sonography revealed a triplet pregnancy in the left fallopian tube (two at interstitial and one at ampullary location). Multiple dose methotrexate (MTX) therapy was applied. Follow-up pelvic ultrasounds and laboratory testing confirmed fetal cardiac activity cessation and decreasing beta-hCG levels. In spite of the decreasing beta-hCG levels the tube's diameter increased, the patient's symptoms escalated, and finally, the level of hemoglobin and hematocrit decreased. Laparotomy was performed with the removal of the left tube and cornual part of the uterus. Our case represents a very rare condition, a unilateral triplet EP after IVF-embryo transfer-the first one ever reported in the literature. After IVF-embryo transfer early ultrasound examinations are important to identify EPs at an early stage when medical management can still be taken into consideration. Strict monitoring is necessary to identify the success of medical intervention or the need for surgery.

Adolescent pneumopericardium and pneumomediastinum after motor vehicle crash and ejection

A 15 year old male was an unrestrained passenger in a high speed motor vehicle crash followed by ejection. The patient was noted to have evidence of bilateral pneumothorax upon arrival in the Emergency Department. Bilateral chest tubes were placed under sterile conditions; however, the left pneumothorax remained, and a second left chest tube was placed. Repeat chest radiographs revealed extensive subcutaneous emphysema, pneumomediastinum, and pneumopericardium. Needle aspiration of the pericardium returned significant quantities of air, an immediate improvement in blood pressures followed. An 18-gauge triple lumen catheter was placed into the pericardial space for additional withdrawal of air via syringe. Mechanisms have been proposed to explain the development of tension pneumopericardium after chest trauma. Early diagnosis is crucial, and may be found on initial chest radiographs. Computed tomography is also an effective method for evaluating the presence of air in the pericardial space and may assist in establishing the diagnosis. Tension pneumopericardium requires immediate recognition and decompression to prevent cardiac tamponade with a fatal circulation collapse, an entity that is as serious as the tamponade resulting from hemopericardium. Traumatic pneumopericardium is rare, but can be a complicated finding associated with high-speed blunt chest trauma. Patients with evidence of pneumopericardium should be closely monitored, particularly those supported by positive pressure ventilation.

A laparoscopic approach to treating torsion of a nonpregnant uterus accompanied by a large ovarian cyst in a premenarchal girl

A 10-year-old premenarchal girl was admitted to our hospital with moderate abndominal pain, although presenting no vomiting or abdominal rebound tenderness. A large abdominal mass was visible and palpable in the periumbilical and epigastric regions. Results of physical examination revealed that the general health status was satisfactory. Computed tomographic scan revealed a large, thin-walled cyst occupying nearly the entire peritoneal cavity. The other viscera were of normal aspect. A laparoscopic approach revealed a left ovarian cystic tumor that was twisted 360° in conjunction with the uterine corpus with hemorrhagic infarction. A partial hysterectomy and a left salpingo-oophorectomy were carried out. The tumor was classified as mature cystic teratoma of the ovary accompanied by hemorrhagic necrosis, not only of the cyst but also of the left uterine tube and the uterine corpus.

Laparoscopic findings in female genital tuberculosis

To evaluate the laparoscopic findings in genital tuberculosis (TB). A total of 85 women of genital TB, who underwent diagnostic laparoscopy for infertility or chronic pelvic pain were enrolled in this retrospective study conducted in our unit at All India Institute of Medical Sciences, New Delhi, India from September 2004 to 2007. The mean age was 28.2 years and the mean parity was 0.24. Most women were from poor socioeconomic status (68.1%). Past history of TB was seen in 29 (34.1%) women with pulmonary TB in 19 (22.35%) women and extrapulmonary in 10 (11.7%) women. Most women presented with infertility (90.6% primary 72.9%; secondary 17.6%) while the rest had chronic pelvic pain (9.4%). The mean duration of infertility was 6.2 years. A total of 49 (57.6%) women had normal menses, while hypomenorrhea, oligomenorrhea, secondary amenorrhea and menorrhagia were seen in 25 (30.1%), 3 (3.5%), 5 (5.9%), and 2 (2.4%) women respectively. Diagnosis of genital TB was made by histopathological evidence of TB granuloma in 16 (18.8%) (Endometrial biopsy in 12.9%, laparoscopy biopsy in 5.9%) women, demonstration of acid fast bacilli (AFB) on microscopy in 2(2.3%), positive AFB culture in 2 (2.3%), positive polymerase chain reaction (PCR) in 55 (64.7%) and laparoscopic findings of genital TB in 40 (47.1%). The various findings on laparoscopy were tubercles on peritoneum (12.9%) or ovary (1.2%), tubovarian masses (7.1%), caseous nodules (5.8%), encysted ascitis in 7.1% women. Various grades of pelvic adhesions were seen in 56(65.8%) women. The various findings on fallopian tubes were normal looking tubes in (7.1%), inability to visualize in 12(14.1%), presence of tubercles on tubes in 3 (3.52%), caseous granuloma in 3 (3.52%), hydrosalpinx in 15 (17.6%) (Right tube 11.7%, left tube 5.9%), pyosalphinx in 3 (3.5%) on right tube and 2 (2.35%) in left tube, beaded tube in 3 (3.5%) on right tube, 4 (4.7%) in left tube with tobacco pouch appearance in 2 (2.35%) women. The right tube was patent in 9 (10.6%) while left tube was patent in 10(11.7%) cases only, while they were either not seen (absent in one case due to previous salphingectomy, inability to see due to adhesion in 14.12%) or blocked at various sites with cornual end being most common in 3 (3.5%) showing multiple block in right tube and 4.7% in left tube. There is a significant pelvic morbidity and tubal damage in genital tuberculosis.

A logical approach to the selection and insertion of double-lumen tubes

There has been a progressive evolution in double-lumen tubes to separate the right and left lungs. The appreciation of the anatomical advantage of the longer left main bronchus has directed anesthetists to prefer a left tube if possible for lung separation. Understanding the dimensions of the tube as well as the variations in the left main bronchus has improved the process of selection and insertion of the double-lumen tubes for lung isolation. Early work focused on the anatomy of the longer left main bronchus. More recent work looked at the tube. This showed that tubes of the same nominal French size were substantially different in the size of the bronchial tube diameter and length. The proposed International Standards Organization standard will more accurately identify tube dimensions. These factors must be considered when selecting a tube for lung separation. Measurement of patient's airway dimensions combined with knowledge of the dimensions of the double-lumen (tracheobronchial) tube plays an important role in lung separation.

Effects of Methotrexate on the Tubal Morphology of Rabbits: Evaluation by Electron Microscopy

Background/Aims: To evaluate by electron microscopy the effects of methotrexate on the tubal morphology of rabbits. Methods: Biopsies were taken from the isthmic portion of both tubes of 4 rabbits in the control group. 1 mg/kg methotrexate was injected in the left tubes and as a control, a 14-gauge fine needle was used to puncture the right tubes of 10 rabbits in the study group. One month later, tubal biopsies were taken from both tubes of every rabbit in the study group. To mimic pregnancy, 100 IU hCG was injected intramuscularly to every rabbit 24 h before every surgery. On examination by electron microscopy, the effects of methotrexate and of the damage with the fine needle on the tubes were compared to the control group. Results: Young epithelial cells of the methotrexate-injected fallopian tubes kept their normal structure, but others contained important ultrastructural changes. These were: nuclear pyknosis, cytoplasmic vacuolization, dilatation of endoplasmic reticulum cisternae, increased cytoplasmic density and compound cilia. Conclusion: Degenerative changes on epithelial cells caused by the temporary blockage of mitotic activity associated with local methotrexate injection are reversible through the formation of new epithelial cells.

Left Right Asymmetry, the Pulmonary Vein, and A-Fib

See related article, pages 902–909 Atrial fibrillation (AF), a common adult cardiac arrhythmia, involves abnormal atrial contractions. As every medical student is taught, it is easily diagnosed as an irregularly irregular pulse and loss of organized atrial activity on an ECG. Clinical interest in AF is considerable because AF is the most common adult arrhythmia that increases in prevalence with age, with 5% of the over 65 population having AF. Moreover, patients with AF have a significantly increased risk of stroke.1 Electrical impulses, critical for a coordinated and physiologic heartbeat, are normally initiated in the sinoatrial (SA) node. However, in AF the disorganized atrial activity overrides normal SA node function resulting in irregular conduction of impulses to the ventricles. In the majority of cases, ectopic electrical activity originates in the pulmonary veins.1 In this issue of Circulation Research , Mommersteeg and colleagues2 make a significant advance in our understanding of pulmonary vein development by making a strong connection between AF and embryonic axis determination. Moreover, their work fits nicely with exciting new data from human genetic studies implicating the same genetic pathways in familial AF.3 Mommersteeg and colleagues make a number of fundamental observations regarding pulmonary vein development. Previous work suggested that pulmonary myocardium derives from atrial myocardium.4 Using lineage tracing, the authors convincingly rule out this possibility. Moreover, they show other data revealing that pulmonary myocardium is derived from Isl1 -positive second heart field and has a distinct origin from the systemic venous circulation.5 Together, these findings suggest that the pulmonary vein myocardium forms by differentiation of mesenchyme around the pulmonary vein. To address this hypothesis, the authors use a Pitx2 mutant mouse model that had been shown to have defects in pulmonary vein development.6 The Pitx (Pituitary homeobox) family of …

Isolation of the Right Upper-Lobe with a Left-Sided Double-Lumen Tube After Left-Pneumonectomy

A patient with a prior left pneumonectomy required surgical drainage of a right upper lobe aspergilloma. A left double-lumen endobronchial tube was placed in the right bronchus intermedius, isolating the right upper lobe while allowing ventilation of the right middle and lower lobes.

Gestational choriocarcinoma arising from a cornual ectopic pregnancy: a case report and review of the literature

Gestational choriocarcinoma associated with ectopic pregnancy is an extremely rare event. We report a case of a choriocarcinoma arising from a cornual pregnancy. The patient is a 35-year-old G8 P2052 who was referred to our department due to failure of treatment for a suspected ectopic pregnancy. The patient had initially been treated with methotrexate injection but her beta-hCG levels reached a plateau 3 weeks later and, despite another two methotrexate injections, started to rise. The patient underwent dilation and curettage that did not reveal any trophoblastic tissue. A diagnostic hysteroscopy that followed demonstrated occluded ostia of the left tube. The patient subsequently underwent diagnostic laparoscopy that revealed a mass in the left cornua, which was removed with wedge-wide resection. Histologic evaluation revealed choriocaricnoma. Appropriate monitoring of beta-hCG titers following conservative management of suspected ectopic pregnancy is important, not only to diagnose persistent ectopic gestation, but also to rule out the presence of malignant trophoblastic disease, albeit the latter is a rare diagnosis.

CONTRAST‐ENHANCED COMPUTED TOMOGRAPHIC IMAGING OF THE AUDITORY TUBE IN MESATICEPHALIC DOGS

Computed tomography after contrast medium injection was performed in three mesaticephalic canine cadavers to image the auditory tube. Cadavers were positioned in lateral recumbency for imaging. A myringotomy incision was made in the left tympanic membrane of each dog, and contrast medium was infused into the ear canal and middle ear through a balloon-tip catheter. With this method, contrast medium filled the left bulla and auditory tube in all three cadavers. Computed tomography following contrast medium injection was effective for evaluation of the canine auditory tube. Future studies are required to determine the usefulness, as well as the safety, of this procedure in the evaluation of the auditory tube in other breeds of dogs as well as dogs with otitis

Przypadek czerniaka złośliwego trąbki słuchowej

Melanomas of the mucous membranes of airway tract constitute around 1% of the total melanomas of head and neck. The most common site of the tumor are the nasal and paranasal sinuses but melanomas of the oral cavity are described too. The location of malignant melanoma in the eustachian tube is very rare. We found five cases of this disease in the literature. In our article we present a 53-year-old woman with progressive left aural fullness and hearing impairment for two months. Clinical examination found left middle ear effusion. The nasopharyngoscopy revealed a bluish red, friable and granulomatous tumor occupying the whole pharyngeal orifice of the left auditory tube. The biopsy speciment was taken which established the diagnosis. Because of localization and spread of the melanoma we had a low opinion of surgical treatment and radiotherapy was recommended. The patient was under constant laryngologic and oncological observation. We did not notice the local recurrence of melanoma. She died two years after making the diagnosis because of the neoplasm dissemination.

Role of hysterosalpingoscintigraphy in the workup of infertility.

To assess the role of hysterosalpingoscintigraphy (HSSG) in the evaluation of fallopian tube patency and function and compare the results with hysterosalpingography (HSG) and laparoscopy (LS). Cross-sectional study. The study was conducted at Multan Institute of Nuclear Medicine and Radiotherapy (MINAR), Multan from August 2004 to February 2005. HSSG was performed after instillation of 4mCi (148 MBq) 99mTechnetium-macroaggregated albumin (99mTc-MAA) in posterior vaginal fornix in 65 patients. Serial static images were acquired in supine position at 1 hour, 2 hours, 3 hours and, if needed, at 24 hours. The results were compared to the findings on LS and HSG. Out of 65 patients, 37 (56.9%) patients had bilateral blocked tubes, 17 (26.1%) patients had bilateral patent tubes, 6 (9.2%) patients had blocked left tube and 5 (7.1%) patients had blocked right tube. The calculated sensitivity, specificity, positive predicted value (PPV), negative predicted value (NPV) and accuracy for HSSG were 90%, 83%, 90% and 90% respectively. The agreement between HSSG and LS was found in 32 out of 35 patients and agreement between HSG and HSSG was found in 24 out of 30 patients. This simple procedure can delineate tubal physiology; in selected cases it can replace HSG and in others augment the information gathered by HSG. HSSG should be part of the infertility workup algorithm.

Perioperative Risk Associated With an Unrecognized Bronchogenic Cyst: Clinical Significance and Anesthetic Management

BRONCHOGENIC CYSTS are developmental abnormalities that may have significant anesthetic and perioperative implications. A case is reported in which the contents of an unrecognized right-lung bronchogenic cyst contaminated the right (nonoperative) lung during a left-lung upper lobectomy. Because of inadequate suctioning and persistent hypoxemia, the left double-lumen endobronchial tube was replaced by a single-lumen endotracheal tube to facilitate aspiration of secretions. The patient developed respiratory failure postoperatively requiring intubation and mechanical ventilation, antibiotic therapy, and respiratory therapy.