Post-thoracotomy intercostal artery pseudoaneurysm manifesting as a chest wall metastasis

Intercostal artery pseudoaneurysm (IAP) represents an extremely rare vascular abnormality developing after an insult to the vascular wall with blood collection within the vascular wall layers and subsequent dilatation. Treatment options, apart from observation, include embolization, endovascular stenting, and surgical correction. We describe the case of a 73-year-old male patient with colonic adenocarcinoma pulmonary metastasis. Repetitive wedge resections and a right lower lobectomy were performed to remove multiple metastatic lesions. At follow-up assessment, the patient reported localized thoracotomy site pain progressing with time and unresponsive to oral analgesics. Chest computed tomography (CT) revealed a pseudoaneurysm of 4-cm diameter of the right 5th intercostal artery. The patient underwent embolization of the lumen and was discharged from the hospital after 24 h. Successive CT re-assessment checks were unremarkable.

Outcomes after repair of complete atrioventricular canal with a modified single-patch technique: a retrospective study

Background

This study aimed to present the short- and midterm outcomes after complete atrioventricular canal defect (CAVC) repair using a single-patch technique.

Methods

This study included 30 children who underwent surgical correction of the CAVC using a single-patch technique.

Results

The median age of the patients was 5.7 months (interquartile range [IQR], 5.0-7.5 months), and 23 patients (76.7%) had type A CAVC. Fourteen patients (46.7%) were female and 17 (56.7%) had been diagnosed with Down syndrome. The in-hospital mortality rate was 0%. No deaths were observed during a median follow-up of 4 years (IQR, 3.5-5.0 years). Patients without Down syndrome were associated with late moderate mitral regurgitation (MR) (p=0.02). Late MR less than moderate degree was observed in 96.6%, 78.5%, and 50% of patients after 2, 4, and 5 years of follow-up, respectively, while late tricuspid valve regurgitation less than moderate degree was observed in 96.7%, 85.9%, and 59.0% of patients after 2, 4, and 6 years of follow-up, respectively. After a median follow-up of 4 years, only one patient had required surgical repair of a left ventricular outflow tract obstruction, which occurred 26 months after the first operation. Multivariable logistic regression analysis adjusted for the type of CAVC, sex, Down syndrome, age, and weight revealed that the absence of Down syndrome was a risk factor for late moderate MR (MR-2) (odds ratio, 0.05; 95% confidence interval, 0.006-0.50; p=0.01).

Conclusion

A single-patch technique for CAVC surgical repair is a safe method with acceptable short- and midterm results.

Association of major postoperative wound and anastomotic complications in thoracic surgery with COVID-19 infection☆

Background

One of the most uncommon manifestations of perioperative Covid-19 infection is impaired wound healing. The aim of this study is to present previously unreported observation of thoracotomy and esophageal anastomosis dehiscence in the course of Covid-19 infection after uncomplicated thoracic surgeries.

Methods

This is a single-center study describing unusual wound and anastomosis complications in COVID-19 patients after uncomplicated thoracic surgeries. Medical data was prospectively collected and retrospectively reviewed. All patients admitted to the hospital were symptom free and tested negative for COVID-19 infection preoperatively. Clinical courses were compared to a non-infected control group from historical data.

Results

The total of 14 patients were included. Study group involved 7 patients with major wound and anastomosis complications concurrent with COVID-19 infection. Control group was composed of 7 patients matched with the type of surgeries and treated before Coronavirus pandemic. Surgeries included lung transplantations, lung cancer surgeries and esophagectomies. The mean age of the study group was 65.7 years. Major wound and anastomosis complications occurred 13.6 days postoperatively while the mean time of Covid-19 detection was 21 days. The course of infection varied from mild to very severe which resulted in 3 deaths due to COVID-19 induced ARDS. The mean time of hospital stay was 40,9 days. There were no differences between both groups in baseline characteristics while hospitalization time was significantly longer in the study group.

Conclusions

COVID-19 infection should be included in differential diagnosis in postoperative patients with major wound or anastomosis complications.

‘One-stop-shop’ diagnosis and stage-adapted surgical therapy for small nodules of early stage lung cancer in a hybrid operating room

Objective

Emergent lung cancer screening programs increased detection of small pulmonary nodules. Anatomical resection in case of early-stage lung cancer with only one intervention becomes increasingly desirable. Current literature lacks procedure data about both diagnosis and subsequent indicated resection. After starting our hybrid operating room program, we reviewed the efficacy of detection, diagnosis and therapy in one-step.

Methods

Undiagnosed pulmonary nodules suspicious of lung cancer, which were not detectable by conventional video-assisted thoracoscopic surgery (VATS) due to localization and size, were scheduled for a hybrid procedure consisting of a cone-beam CT-guided hookwire insertion and C-arm assisted thoracoscopic wedge resection for frozen section. All procedures were analyzed for perioperative outcomes including success rate of image-guided nodule resection and rate of concomitant correct anatomical resection.

Results

Between July 2020 and July 2021, 23 patients with 25 nodules underwent image-guided VATS (iVATS) in the hybrid room. Twenty-two nodules were successfully marked by hookwire, three nodules were detected by ultrasound in one case and palpation in two cases. In 16 patients (70%) wedge resection with frozen section showed malignancy. Five patients with previous history of operated lung cancer received only a diagnostic wedge, as frozen section could not differentiate between primary or metastatic lung cancer. Eleven patients (48%) had early-stage primary lung cancer (8 adenocarcinoma, one typical carcinoid, one small-cell lung cancer and one squamous-cell lung cancer). Ten of them (91%) received a synchronous completion anatomical resection (seven lobectomies, three segmentectomies). In one patient, malignancy was only confirmed in final histology.

Conclusion

One-stop-shop diagnosis and treatment by iVATS with frozen section and concomitant completion anatomical resection in a hybrid operating room for otherwise non-well approachable early stage lung cancer is patient-convenient for the increasingly detected small pulmonary nodules.

HeartMate 3 left ventricular assist device implant after excision of a large apical aneurysm

The presence of a left ventricular apical aneurysm may pose a technical challenge during implantation of a left ventricular assist device (LVAD). We describe implantation of a HeartMate III LVAD under cardioplegic arrest. A ventricular aneurysmectomy was performed and the LVAD was implanted at the left ventricular apex at the level of the transition zone between the scar tissue and the viable myocardium. Two pursestring 2-0 Prolene Fontan sutures were placed circumferentially at the transition zone to make up for the size discrepancy between the left ventricular opening and the HeartMate 3 pump. The echocardiographic analysis demonstrated optimal inflow cannula orientation, and the patient had an uneventful recovery.

Resection of abdominal inferior vena cava without graft interposition: Considerations in preserving renal function

The management of tumors involving or infiltrating the inferior vena cava (IVC) constitutes a great surgical challenge, since radical resection affords patients the only possibility for long-term survival. These tumors can be resected without graft interposition, provided that there is adequate collateral circulation and that the renal function can be secured. Meanwhile, ligation of the left renal vein may be possible due to the existence of collateral circulation through the adrenal and gonadal veins. We briefly present our experience on renal outflow preservation through implantation of the right renal vein into the IVC stump or through diversion of the left renal vein into the inferior mesenteric vein.

Thyroid hormones alterations during acute liver failure: possible underlying mechanisms and consequences

Thyroid hormones are now recognized to change in different disease states with important consequences on severity and prognosis of disease. However, little is known about thyroid hormones' alterations in acute liver failure (ALF). To study the changes in thyroid hormones and cardiac thyroid receptors during ALF, we subjected seven female pigs to surgical liver devascularization. Liver function biochemical markers, thyroid hormones, endogenous opioids, malondialdehyde (MDA), and interleukins 1 and 6 were measured in serum for 24 h postoperatively. Heart biopsies were harvested at the end of the experiment. Baseline heart biopsies were taken from five additional animals. Serum thyroxin (T(4)) and triiodothyronine (T(3)) levels markedly decreased, whereas free-triiodothyronine and thyroxin-stimulating hormone levels did not change. T(4) and T(3) levels correlated with the degree of liver failure and with MDA and interleukin-6 levels. Beta-endorphin levels initially increased, whereas levels of leucine-enkephalin did not change. Thyroid hormone receptor-alpha1 protein expression in the heart decreased 1.6-fold after ALF, whereas myocardial myosin isoform expression remained unchanged. The downregulation of T(4) and T(3) levels during ALF seems to correlate well with the severity of disease. This downregulation related to inflammation and oxidative stress and resulted in changes in myocardial thyroid receptors.

Intermittent obstructive jaundice following gastric band placement

Complications of laparoscopic adjustable gastric banding occur in 10 - 20% of patients. However, hepatobiliary complications of this procedure are very rare. We report a unique case of gastric band misplacement around the hepato-duodenal ligament. The patient developed obstructive jaundice several months after the gastric band placement and suffered recurrent episodes of obstructive jaundice and cholangitis that were initially erroneously attributed to fatty infiltration of the liver. Further diagnostic work-up demonstrated the presence of the gastric band in the hepatic hilum. Exploratory laparotomy confirmed the diagnosis, and the band was removed. Jaundice reversed and hepatic function was restored following removal of the occluding band.

Changes in oxyhemoglobin dissociation curve in intrabdominal organs during pig experimental orthotopic liver transplantation

Liver transplantation has become a gold standard treatment for irreversible liver disease. Conventional measures of oxygenation are inadequate to understand the dynamics of regional oxygen metabolism during liver transplantation because they represent global markers of tissue dysoxia. Therefore, the addition of an assessment of the hemoglobin O(2) binding capacity can give a better insight into systemic and regional tissue oxygenation and can reflect a more accurate estimation of oxygen release to the tissues than can the hemoglobin, the PaO(2) and SaO(2) alone. This prospective study was designed to evaluate possible alterations in the oxyhemoglobin dissociation curve of vital end organs (small bowel, liver, and kidney) in an experimental liver transplantation model. Fifteen pigs with body weights ranging from 25 to 30 kg were used for the study. Five healthy pigs underwent a sham operation under general anesthesia (group A-control). Ten pigs underwent orthotopic liver transplantation (OLT). Five of them were healthy (group B), whereas the other five were in acute liver failure, which had been surgically induced (group C). Systemic arterial blood pressure, cardiac index, and pulmonary and systemic vascular resistance indexes were measured. Venous blood gas analysis was also performed from pulmonary artery, superior mesenteric, hepatic, and renal veins at well-defined timepoints during the course of the OLT. A statistically significant (P < 0.05) decrease of P(50) in groups B and C compared with group A was observed 30 minutes after reperfusion in the systemic circulation, hepatic, and renal veins. This coincided with a decrease in animal temperature 30 minutes after reperfusion. Regarding group C, after reperfusion of the newly transplanted liver there was a significant increase of P(50) in the small bowel in comparison to baseline values. In conclusion, these changes in P(50) may suggest the occurrence of abnormal tissue oxygenation after reperfusion.