Transdiaphragmatic nephrectomy with synchronous pulmonary and anterior thoracic wall mass metastasectomy in a young male with metastatic renal cell carcinoma; a single-incision approach.

Renal cell carcinoma represents approximately 3% of all cancers, with the highest incidence occurring in the western world. Around 33% of the patients experience metastatic disease at diagnosis. Since the approval of the first targeted therapy, the treatment of metastatic renal cell carcinoma (mRCC) has positively changed, but the surgical treatment of the primary tumor, and metastases if possible, is sometimes crucial in selected patients controlling the burden of cancer sites with the intention to improve survival. We, herein, report on a case of a young male patient presented in the emergency room with gross hematuria which underwent transdiaphragmatic nephrectomy with synchronous pulmonary and anterior thoracic wall mass metastasectomy with a single thoracic incision due to mRCC. Achieving a full response in patients with mRCC is extremely rare only with medical treatment. The role of complete surgical metastasectomy is questioned, but there are several studies that support its efficacy in achieving metastases free status prolonged overall survival and better quality of life. The therapeutic treatment plan for these patients should be discussed within dedicated multidisciplinary cancer centers and focus on each patient individually and they should be offered a closed follow-up strategy.

Benign emptying of the post-pneumonectomy space: recognizing this rare complication retrospectively.

Patients presenting with a sudden drop in the pleural fluid level after a pneumonectomy in the absence of a recognizable bronchopleural fistula (BPF) have been classified as cases of benign emptying of the post-pneumonectomy space (BEPS). A retrospective study of 1378 pneumonectomies identified 4 cases of BEPS (0.29%). The patients were men; median age 64 years and all had undergone a right pneumonectomy. The median time at diagnosis was 31 days postoperatively and the median follow-up time was 31 months. None of the patients experienced a documented BPF or empyema. Although BEPS is an extremely rare complication, early recognition and close patient monitoring will prevent unnecessary interventional strategies.

Pneumonectomy and contralateral metastasectomy through a single thoracotomy in a 9-year-old girl with a giant tumor.

A 9-year-old girl with a giant tumor of the right lung and an isolated metastasis of the left lower lobe underwent combined pneumonectomy and metastasectomy through means of a right thoracotomy. Her postoperative course was uneventful. The operative approach of a tumor of this scale and the concurrent contralateral metastasectomy are described and discussed.

Emerging surgical pathways of thoracotomy.

Thoracic incisions are the portals of choice for accessing thoracic organs. There are instances, however, that more than one incision are required at the same or a later stage, in order to access other, thoracic or extrathoracic, organs for more complicated procedures. Then again, a single thoracic incision may offer more than adequate access to extrathoracic organs and in selected cases becomes valuable surgical approach to organs of the upper abdomen or the contralateral hemithorax. The experience with this technique is discussed.

Cavitating lung lesion as a manifestation of inflammatory tumor (pseudotumor) of the lung: A case report and literature review.

PATIENT: Female, 60 FINAL DIAGNOSIS: Inflammatory pseudotumor of the lung Symptoms: Cough dry • fever MEDICATION: - Clinical Procedure: - Specialty: - OBJECTIVE: Rare disease. BACKGROUND: Inflammatory pseudotumor of the lung involves a benign, non-neoplastic lung lesion of unknown etiology. CASE REPORT: We present a case of a 60-year-old female smoker who had been under intermittent immunosuppressive medication for discoid lupus, who was admitted to hospital with fever of 39.5°C of 10-day duration, not responding to an oral cephalosporin. Chest CT examination showed a cavitating opacity in the upper zone of the left lung. It was not feasible to establish a diagnosis based on clinical and laboratory testing nor based on CT scanning and bronchoscopy. Thus, the patient underwent left thoracotomy and sphenoid resection of the lesion, which was sent for biopsy. The histopathologic features aided by immunohistochemical staining proved the lesion to be an inflammatory pseudotumor of the lung. CONCLUSIONS: The case is reported because of the extremely rare radiologic presentation of the development of a lung pseudotumor emerging as a cavitated lesion, which relapsed during the follow-up period while the patient was still under immunosuppressive medication.

Minimal invasive coronary artery fistula ligation.

A coronary artery fistula was surgically ligated in a 38-year-old woman via a left anterior mini-thoracotomy without the use of cardiopulmonary bypass. In selected cases, this surgical approach can provide an excellent surgical exposure for coronary artery fistula ligation. It also offers an excellent cosmetic result and shorter hospital stay.

Chylothorax complicating thoracic surgery: conservative or early surgical management?

Postoperative chylothorax is a rare complication in thoracic surgery. There is considerable controversy concerning the management of chylothorax with some physicians favoring conservative treatment while others favor a surgical one. Considering the current surgical experience with VATS and by reviewing the problems and outcome of conservative management, the guidelines regarding timing of surgery in patients with chylous leak need to be revised.

Late diagnosis of silent thoracic aortic rupture presented as a right pleural effusion.

Patients with ruptured thoracic aortic aneurysm rarely present in a stable clinical condition. A man was referred to our hospital with the diagnosis of ruptured saccular aneurysm of the descending thoracic aorta. He successfully underwent both endovascular graft repair and open thoracotomy.

Chylothorax complicating thoracic aortic surgery.

OBJECTIVE: Chylothorax is a very rare complication of patients undergoing thoracic aortic aneurysm repair. Possible mechanisms of this condition during thoracic aorta operations and current therapeutic strategies are analyzed according to our experience and thorough search of the English literature. METHODS: Current experience with chylothorax occurring during thoracic aortic surgery is analyzed in this review by collecting data retrieved from English literature research. RESULTS: Significant risk factors for postoperative chylothorax development after thoracic aorta surgical procedures are thoracic aortic reoperations and descending thoracic repairs. Various treatment modalities from conservative to operative intervention have been proposed. CONCLUSION: Currently, the morbidity and mortality have improved due to prompt management. Surgical intervention is needed when response to conservative treatment has failed.

Simple laboratory parameters which can determine the clinical state of patients after pneumonectomy for lung cancer.

INTRODUCTION: The clinical state of patients after pneumonectomy varies from normal to seriously impaired daily life. The objective of the study is to identify laboratory parameters which determine the clinical postpneumonectomy state. METHODS: Thirty-five patients who underwent pneumonectomy for lung carcinoma (mean age: 61.5 +/- 7.2 years, left sided: 23) were prospectively studied with preoperative and 6-month postoperative spirometry, Doppler echocardiography for calculation of right ventricular systolic pressure and arterial blood gas. The clinical postpneumonectomy state was defined as the class of dyspnea on exertion: I = on heavy exertion, II = on moderate exertion, III = on mild exertion, IV = on minimal exertion. RESULTS: Postoperative forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC) and percent of the predicted FVC were significantly lower in patients with class III and IV than in patients with class I and II dyspnea, while right ventricular systolic pressure and percent reduction of FVC and FEV1 were significantly higher in patients with class IV dyspnea. On multiple regression analysis, postoperative FEV1 and percent reduction of FVC were found to strongly affect the postpneumonectomy state. Right pneumonectomy, obstructive pattern at preoperative spirometry, bronchial obstruction limited to up to three bronchopulmonary segments at preoperative bronchoscopy and predicted FEV1 less than 1.4 liter by the ventilation/perfusion lung scanning were connected with seriously impaired postpneumonectomy state. CONCLUSIONS: The postpneumonectomy state is affected by low actual postpneumonectomy FEV1 values and serious percent reduction of FVC from preoperative values. Right pneumonectomy together with obstructive ventilatory pattern and minimal bronchial obstruction are preoperative factors that result in serious reduction of FEV1 and percent reduction of FVC.

Study on the late effect of pneumonectomy on right heart pressures using Doppler echocardiography.

OBJECTIVE: Changes in the pulmonary artery systolic pressure (PASP) and the dimensions of the right ventricle (RV) of the heart, six months after pneumonectomy, were evaluated in order to detect the influence of pneumonectomy on right heart function. METHODS: 35 patients undergoing pneumonectomy (Group A) and 17 patients undergoing lobectomy or bilobectomy (Group B) were evaluated prospectively with spirometry, arterial blood gases determination and Doppler echocardiography at rest, preoperatively and six months postoperatively. Patients of both groups had normal preoperative PASP, RV dimensions and left ventricular ejection fraction. PASP was calculated using the equation: PASP=4x(maximal velocity of the tricuspid regurgitant jet)2+10 mmHg. FEV1, FVC, partial pressures of oxygen (pO2) and carbon dioxide in the arterial blood were considered as the main determinants of postoperative lung function. RESULTS: PASP increased significantly six months postoperatively in both groups (P<0.05). Mean PASP in Group A (40.51+/-12.52 mmHg) was significantly higher (P=0.012) than in Group B (32.88+/-5.25 mmHg). Mean PASP after right pneumonectomy (48.33+/-10.61 mmHg) was significantly higher (P=0.002) than after left pneumonectomy (35.26+/-10.83 mmHg). The incidence of RV dilatation was higher in Group A (60%) than in Group B (23.52%). RV dilatation was related with elevated PASP values in both groups (P<0.001 and P=0.034, respectively). Increased age (P<0.001), significant percent FVC reduction from preoperative values (P=0.012) and low pO2 values (P=0.001) were detected as strong predisposing factors for postpneumonectomy PASP elevation. CONCLUSIONS: Pneumonectomy is related with postoperative elevation of PASP and RV dilatation, especially right pneumonectomy. Significant percent FVC reduction, increased age and low pO2 values are the main responsible factors for elevation of the 6-month postoperative PASP values.

Combined repair of ascending aortic pseudoaneurysm and abdominal aortic aneurysm: in a patient with Marfan syndrome.

Pseudoaneurysms of the ascending aorta after the original inclusion/wrap technique of the Bentall procedure present a difficult surgical management problem and are associated with substantial morbidity and mortality. Patients with Marfan syndrome frequently develop aneurysms and dissections that involve multiple aortic segments. We present the case of a Marfan patient who successfully underwent repair of a giant ascending aortic pseudoaneurysm and concomitant repair of an abdominal aortic aneurysm. An aggressive surgical strategy followed by life-long cardiovascular monitoring is warranted in order to prolong the survival of these patients.

Surgical treatment for aneurysm at the origin of an aberrant right subclavian artery.

Atherosclerotic aneurysms at the origin of an aberrant right subclavian artery (ARSA) are extremely rare entities of congenital origin. We report a case of a 62-year-old man who presented with dyspnea and upper chest pain. The CT scan and digital subtraction angiography revealed a 7-cm aneurysm of an ARSA arising from Kommerell's diverticulum. Deep hypothermic circulatory arrest was instituted and a transaortic approach was used for closure of the origin of the aneurysm with a prosthetic patch. A Dacron graft was interposed between the right subclavian artery and the ascending aorta and the aneurysmal sac was resected. The patient had an uneventful recovery.

Factors associated with cardiac rhythm disturbances in the early post-pneumonectomy period: a study on 259 pneumonectomies.

OBJECTIVE: To identify predisposing factors associated with cardiac rhythm disturbances during the early post-pneumonectomy period (first 7 postoperative days). MATERIALS AND METHODS: During the study period (1995-1999), 259 pneumonectomies were performed for malignant (244 cases) or benign disease (15 cases). Postoperative monitoring of patients included continuous arterial pressure - rhythm monitoring and pulse oximetry. Cardiac rhythm disturbances during the intensive care unit stay were detected on the monitor screen and recorded with a 12-lead electrocardiogram. Cardiac rhythm disturbances associated with electrolytes or fluid balance abnormality, mediastinal deviation or surgical postoperative complications were excluded from the study. Age of patients, preexisting cardiac disease, side of pneumonectomy, intrapericardial procedures, stage of the malignant disease, expected postoperative FEV(1)<1200 ml, intraoperative transfusions of packed red cells, elevated right heart pressures, low postoperative serum magnesium levels and long operative times were considered as predisposing factors for the development of post-pneumonectomy cardiac rhythm disturbances. Statistical analysis has been made using logistic regression analysis, Student t-test and chi-square test. RESULTS: Cardiac rhythm disturbances were detected in 49 patients (18.91%). Atrial fibrillation/flutter (31 cases), supraventricular tachycardia (14 cases), and premature ventricular contractions (four cases) were the observed rhythm disturbances. Right pneumonectomy versus left pneumonectomy (P<0.0001) and intrapericardial pneumonectomy versus standard pneumonectomy (P<0.0001) were identified as strong predisposing factors for the establishment of post-pneumonectomy cardiac rhythm disturbances. Patients who established post-pneumonectomy cardiac rhythm disturbances had significantly higher (P=0.024) right ventricular systolic pressure (42.50+/-15.50 mmHg) when compared with patients who had postoperative sinus rhythm (29.07+/-7.71 mmHg) and had also longer operative times than patients who did not develop rhythm disturbances (P=0.015). Mortality rate in patients who developed post-pneumonectomy rhythm disturbances was 20.40%. CONCLUSIONS: Cardiac rhythm disturbances observed early after pneumonectomy are mainly of supraventricular origin, complicating right and intrapericardial pneumonectomies, patients with elevated right heart pressures and long operative times, and are associated with high mortality rates.

Chest wall hydatidosis as the unique location of the disease: Case report and review of the literature.

The chest wall is a rare location of secondary hydatidosis, but secondary hydatidosis may occur from the rupture of a lung cyst, from a liver cyst invading the diaphragm into the pleural cavity, following previous thoracic surgery for hydatidosis, or by hematogenous spread. This report describes a case of chest wall hydatidosis, which was the primary disease site in the patient, who had no previous history or current disease (hydatidosis) at other sites. The cyst invaded and partially destroyed the 9th and 10th ribs and the 10th thoracic vertebra, and protruded outside the pleural cavity through the 9th intercostal space. Preoperative albendazole administration for 10 days, surgical resection of the disease through a posterolateral thoracotomy incision, and postoperative albendazole treatment resulted in a cure with no evidence of local recurrence or disease at other sites in four years of follow-up.