Results of upfront surgery in a mixed stage population of patients with esophageal carcinoma: early outcome and long term survival.

PURPOSE: To evaluate early outcome and long term survival in a mixed stage population of patients undergoing upfront esophagectomy for esophageal cancer. METHODS: Retrospective analysis of the data of 92 patients who underwent esophagectomy (thoracoabdominal: 76, Ivor-lewis: 16) between 1998 and 2017. Tumors were located in gastro-esophageal junction (52), lower third (31) and middle third (9) of the esophagus. Histology was: 73 adenocarcinomas and 19 squamous cell carcinomas. The stomach was used for reconstruction in 90 patients. A neck anastomosis was performed in 7 patients. End points of the study included: mortality, morbidity and long term survival. Kaplan-Meier and Cox regression analyses were used to identify prognostic factors for survival. RESULTS: The mortality was 10.9% and 29 patients presented 49 complications. Anastomotic dehiscence occurred in 17.4% of the patients and represented the most common cause of death with mortality of 37.5%. Reoperation was necessary in 14 patients. Median survival reached 25 months with 3 and 5 year survival of 30.5% and 21% respectively. Early stage tumors, absence of nodal disease, well differentiated carcinomas and lymph node ratio ≤ 0.2 were associated with 5 year survival of 82.6%, 81.6%, 83.3% and 40.4% respectively. In multivariate analysis early stage disease (OR: 15.746, 95%CI: 4.332-58.579, p < 0.001) and lymph node ratio (OR: 1.700 95%CI: 1.051-2.752, p = 0.031) were statistically associated with long term survival. CONCLUSIONS: Our results support the role of upfront surgery as the treatment of choice in early stage esophageal carcinomas without or with low nodal involvement.

Simultaneous Bilateral Spontaneous Pneumothorax in an Adult Patient With Pulmonary Langerhans Cell Histiocytosis: A Case Report.

We report a case of a young female with known history of pulmonary Langerhans cell histiocytosis who was initially presented in the emergency department of a university hospital with respiratory distress. Clinical assessment and diagnostic workup revealed left hemithorax subcutaneous emphysema, bilateral pneumothorax, and atelectasis in both lower lung lobes. The patient was treated with bilateral staged thoracoscopic bullectomy and mechanical abrasion of the parietal pleura combined with chemical pleurodesis with talc. A new occurrence of right-sided pneumothorax was noticed 3 days after surgery, which was treated with chest tube insertion and chemical pleurodesis. The aforementioned surgical approach resulted in complete lung expansion and the patient's full recovery. A review of pulmonary Langerhans cell histiocytosis and treatment options in cases of pneumothorax due to lung histiocytosis is also presented in this report.

Coil embolization of traumatic pseudoaneurysm of right internal thoracic artery.

Traumatic injury to the chest and internal thoracic artery is a perplexing problem that is difficult to diagnose and open to different treatment options. Internal thoracic artery pseudoaneurysms are an extremely rare vascular abnormality. We report the case of a patient with a pseudoaneurysm of the musculophrenic artery, a branch of right internal thoracic artery, caused by a penetrating injury of the chest.

Airway trauma: a review on epidemiology, mechanisms of injury, diagnosis and treatment.

Airway injuries are life threatening conditions. A very little number of patients suffering air injuries are transferred live at the hospital. The diagnosis requires a high index of suspicion based on the presence of non-specific for these injuries symptoms and signs and a thorough knowledge of the mechanisms of injury. Bronchoscopy and chest computed tomography with MPR and 3D reconstruction of the airway represent the procedures of choice for the definitive diagnosis. Endotracheal intubation under bronchoscopic guidance is the key point to gain airway control and appropriate ventilation. Primary repair with direct suture or resection and an end to end anastomosis is the treatment of choice for patients suffering from tracheobronchial injuries (TBI). The surgical approach to the injured airway depends on its location. Selected patients, mainly with iatrogenic injuries, can be treated conservatively as long as the injury is small (<2 cm), a secure and patent airway and adequate ventilation are achieved, and there are no signs of sepsis. Patients with delayed presentation airway injuries should be referred for surgical treatment. Intraoperative evaluation of the viability of the lung parenchyma beyond the site of stenosis/obstruction is mandatory to avoid unnecessary lung resection.

Save or sacrifice the internal mammary pedicle during anterior mediastinotomy?

Ligation and dissection of internal mammary vessels is the most under-estimated complication of anterior mediastinotomy. However, patients requiring anterior mediastinotomy may experience long survival that makes the development of ischemic heart disease throughout their life possible. Therefore, the un-judicial sacrifice of the internal mammary pedicle may deprive them from the benefit to have their internal mammary artery used as a graft in order to successfully bypass severe left anterior descending artery stenoses. We recommend the preservation of the internal mammary pedicle during anterior mediastinotomy, which should be a common message among our colleagues from the beginning of their training.

Right upper lobe partial anomalous pulmonary venous connection.

Partial anomalous pulmonary venous return (PAPVR) is a left-to-right shunt where one or more, but not all, pulmonary veins drain into a systemic vein or the right atrium. We report a case of a 45-year-old male with PAPVR to superior vena cava which was incidentally discovered during a right lower bilobectomy for lung cancer.

Pancoast tumors: characteristics and preoperative assessment.

Superior sulcus tumors (SSTs), or as otherwise known Pancoast tumors, make up a clinically unique and challenging subset of non-small cell carcinoma of the lung (NSCLC). Although the outcome of patients with this disease has traditionally been poor, recent developments have contributed to a significant improvement in prognosis of SST patients. The combination of severe and unrelenting shoulder and arm pain along the distribution of the eighth cervical and first and second thoracic nerve trunks, Horner's syndrome (ptosis, miosis, and anhidrosis) and atrophy of the intrinsic hand muscles comprises a clinical entity named as "Pancoast-Tobias syndrome". Apart NSCLC, other lesions may, although less frequently, result in Pancoast syndrome. In the current review we will present the main characteristics of the disease and focus on the preoperative assessment.

Hemodynamic effects of combination therapy with inhaled nitric oxide and iloprost in patients with pulmonary hypertension and right ventricular dysfunction after high-risk cardiac surgery.

OBJECTIVE: The purpose of this study was to evaluate the hemodynamic effects of inhaled nitric oxide (NO) plus aerosolized iloprost in patients with pulmonary hypertension/right ventricular dysfunction after cardiac surgery. DESIGN: A retrospective study. SETTING: A single center. PARTICIPANTS: Eight consecutive patients with valve disease and postextracorporeal circulation (ECC) pulmonary hypertension/right ventricular dysfunction. INTERVENTION: The continuous inhalation of nitric oxide (10 ppm) and iloprost, 10 µg, in repeated doses. MEASUREMENTS AND MAIN RESULTS: The hemodynamic profile was obtained before inhalation, during the administration of inhaled NO alone (prior and after iloprost), and after the first 2 doses of iloprost. Tricuspid annular velocity and tricuspid annular plane systolic excursion were estimated at baseline and before and after adding iloprost. At the end of the protocol, there were significant decreases in pulmonary vascular resistance (p < 0.001), the mean pulmonary arterial pressure (p < 0.001), and the mean pulmonary artery pressure/mean arterial pressure ratio (p = 0.006). Both tricuspid annular velocity (p < 0.001) and tricuspid annular plane systolic excursion (p < 0.001) increased. The cardiac index (p < 0.001) and venous blood oxygen saturation (p = 0.001) increased throughout the evaluation period. Each iloprost dose was associated with further decreases in pulmonary vascular resistances/pressure. By comparing data at the beginning of inhaled NO with those after the second dose of iloprost, the authors noticed decreases in pulmonary vascular resistances (p = 0.004) and the mean pulmonary artery pressure (p = 0.017) and rises in tricuspid annular velocity (p < 0.001) and tricuspid annular systolic plane systolic excursion (p < 0.001). CONCLUSIONS: Inhaled NO and iloprost significantly reduced pulmonary hypertension and contributed to the improvement in right ventricular function. Inhaled NO and iloprost have additive effects on pulmonary vasculature.

Inhaled nitric oxide plus iloprost in the setting of post-left assist device right heart dysfunction.

BACKGROUND: Pulmonary hypertension and right ventricular (RV) dysfunction may complicate the implantation of a left ventricular assist device (LVAD). We examined whether inhaled vasodilators can sufficiently reduce RV afterload, avoiding the need for temporary RV mechanical support. METHODS: The study includes 7 patients with RV dysfunction after LVAD insertion. Treatment consisted of inotropes, inhaled nitric oxide (10 ppm), and iloprost (10 µg) in repeated doses. Full hemodynamic profile was obtained before inhalation, during administration of inhaled NO alone (before and after iloprost), as well as after the first two doses of inhaled iloprost. Tricuspid annular velocity was estimated at baseline and before and after adding iloprost. RESULTS: There was a statistically significant reduction in pulmonary vascular resistance (PVR), mean pulmonary artery pressure (MPAP), RV systolic pressure, and pulmonary capillary wedge pressure, and a considerable increase in LVAD flow, LV flow rate index, and tricuspid annular velocity at all points of evaluation versus baseline. By the end of the protocol, MPAP/mean systemic arterial pressure, and PVR/systemic vascular resistance ratios were reduced by 0.17±0.03 (95% confidence interval, 0.10 to 0.25, p=0.001) and 0.12±0.025 (95% confidence interval, 0.06 to 0.18; p=0.003), respectively. The tricuspid annular velocity increased by 2.3±0.18 cm/s (95% confidence interval, 1.83 to 2.73 cm/s; p<0.001). Pairwise comparisons before and after iloprost showed an important decrease in PVR (p=0.022), MPAP (p=0.001), pulmonary capillary wedge pressure (p=0.002), and RV systolic pressure (p<0.001), and a rise in tricuspid annular velocity (p=0.008). CONCLUSIONS: Inhaled vasodilators mainly affected the pulmonary vasculature. Combination treatment with inhaled NO and iloprost sufficiently decreased PVR and MPAP on the basis of an additive effect, improved RV function, and avoided the need for RV assist device.

Surgical decision making in tracheobronchial injuries on the basis of clinical evidences and the injury's anatomical setting: a retrospective analysis.

BACKGROUND: Airway trauma is a life threatening condition requiring prompt diagnosis and management. We present our experience focusing on the diagnosis, airway management and treatment. MATERIAL AND METHODS: This is a retrospective analysis of 25 patients treated for tracheal or bronchial injury within a 12 year period. Data collected included: mechanism and sites of injury, associated injuries, clinical presentation, indications for surgical management, treatment and outcome. RESULTS: There were 15 traumatic injuries (blunt/penetrating, 10/5 patients) and 10 post-intubation perforations. The most common findings included subcutaneous emphysema, pneumomediastinum and pneumothorax. Endotracheal intubation was carried out under bronchoscopic guidance. Tracheostomy was performed in one patient. Most injuries were located at the trachea/carina. Surgical treatment was undertaken in 22 patients. In 13 of them, all with traumatic injuries, the surgical treatment was decided on the basis of the clinical and radiological findings. The decision for surgery in post-intubation injuries was based on the proximity of the injuries to the carina (2 patients), the suspicion of an unsafe airway (1 patient) and the present of posterior tracheal wall perforations>2 cm (2 patients). The surgical approach for the repair was dictated by the location of the injury. There was a single case of perioperative mortality in the subgroup of patients with traumatic injuries. CONCLUSIONS: Surgical primary repair represents the treatment of choice in airway injuries with the approach depending on the specific site of the lesion. Therefore we consider valuable the division of the tracheobronchial tree in 4 zones.

Prognostic factors of atrial fibrillation following elective coronary artery bypass grafting: the impact of quantified intraoperative myocardial ischemia.

BACKGROUND: Atrial fibrillation (AF) occurs in 28-33% of the patients undergoing coronary artery revascularization (CABG). This study focuses on both pre- and peri-operative factors that may affect the occurrence of AF. The aim is to identify those patients at higher risk to develop AF after CABG. PATIENTS AND METHODS: Two patient cohorts undergoing CABG were retrospectively studied. The first group (group A) consisted of 157 patients presenting AF after elective CABG. The second group (group B) consisted of 191 patients without AF postoperatively. RESULTS: Preoperative factors presenting significant correlation with the incidence of post-operative AF included: 1) age > 65 years (p = 0.029), 2) history of AF (p = 0.022), 3) chronic obstructive pulmonary disease (p = 0.008), 4) left ventricular dysfunction with ejection fraction < 40% (p = 0.015) and 5) proximal lesion of the right coronary artery (p = 0.023). The intraoperative factors that appeared to have significant correlation with the occurrence of postoperative AF were: 1) CPB-time > 120 minutes (p = 0.011), 2) myocardial ischemia index < 0.27 ml.m2/Kg.min (p = 0.011), 3) total positive fluid-balance during ICU-stay (p < 0.001), 4) FiO2/PO2 > 0, 4 after extubation and during the ICU-stay (p = 0.021), 5) inotropic support with doses 15-30 µg/Kg/min (p = 0.016), 6) long ICU-stay recovery for any reason (p < 0.001) and perioperative myocardial infarction (p < 0.001). CONCLUSIONS: Our results suggest that the incidence of post-CABG atrial fibrillation can be predicted by specific preoperative and intraoperative measures. The intraoperative myocardial ischemia can be sufficiently quantified by the myocardial ischemia index. For those patients at risk we would suggest an early postoperative precautionary anti-arrhythmic treatment.

Transternal repair of a giant Morgagni hernia causing cardiac tamponade in a patient with coexisting severe aortic valve stenosis.

BACKGROUND: Foramen of Morgagni hernias have traditionally been repaired by laparotomy, laparoscopy or even thoracoscopy. However, the trans-sternal approach should be used when these rare hernias coexist with other cardiac surgical diseases. CASE PRESENTATION: We present the case of a 74 year-old symptomatic male with severe aortic valve stenosis and global respiratory failure due to a giant Morgagni hernia causing additionally cardiac tamponade. The patient underwent simultaneous repair of the hernia defect and aortic valve replacement under cardiopulmonary bypass. The hernia was repaired through the sternotomy approach, without opening of its content and during cardiopulmonary reperfusion. CONCLUSIONS: Morgagni hernia can rarely accompany cardiac surgical pathologies. The trans-sternal approach for its management is as effective as other popular reconstructive procedures, unless viscera strangulation and necrosis are suspected. If severe compressive effects to the heart dominate the patient's clinical presentation correction during the cardiopulmonary reperfusion period is mandatory.

Superior vena cava syndrome in a patient with previous cardiac surgery: what else should we suspect?

BACKGROUND: Although mediastinal tumors compressing or invading the superior vena cava represent the major causes of the superior vena cava syndrome, benign processes may also be involved in the pathogenesis of this medical emergency. One of the rarest benign causes is a pseudoaneurysm developing in patients previously having heart surgery. CASE REPORT: We present the case of a large pseudoaneurysm of the ascending aorta, five years after primary surgery, with a significant compression of the right mediastinal venous system causing superior vena cava syndrome, detected at chest CT angiography. Perioperative findings showed two rush out points both coming from the distal aortic suture line which was performed five years ago. The patient underwent reoperation under circulatory arrest facilitating safe exploration and repair of the distal anastomotic leaks CONCLUSION: Enhanced chest CT should be always undertaken in all patients with superior vena cava syndrome, especially in those previously having cardiac or aortic surgery to correctly evaluate the presence of a pseudoaneurysm. Mass effect to the superior vena cava makes necessary an open surgical treatment of the pseudoaneurysm so as to concurrently resolve the right mediastinal venous system's compression. Surgery should be performed in terms of safe approach to avoid exsanguination and cerebral malperfusion.

Cardiac surgery in a patient with retroperitoneal fibrosis and heart valvulopathy, both due to pergolide medication for Parkinson's disease.

Retroperitoneal fibrosis is best described as a chronic inflammatory process which may be idiopathic, but can rarely be brought about by medications, such as pergolide, used for treating Parkinson's disease. Pergolide can produce a fibrotic process in heart valves, resulting in valve insufficiency in up to 25% of cases. Herein we describe the case of a 68-year-old man who received pergolide for 2 years for Parkinson's disease. The patient developed retroperitoneal fibrosis resulting in renal failure from ureteral obstruction necessitating ureteral stenting, as well as significant aortic and mitral valve insufficiency. He successfully underwent surgery for combined aortic valve, mitral valve and ascending aorta replacement because of severe valve insufficiency and dilated (d = 5.8 cm) ascending aorta. Retroperitoneal fibrosis improved with pergolide cessation and corticosteroid treatment. This is the second case reported in the literature, of a patient who had double valve and ascending aorta replacement surgery because he suffered from this rare but serious adverse effect of dopamine agonists used for managing Parkinson's disease.

Modified maximal thymectomy for myasthenia gravis: effect of maximal resection on late neurologic outcome and predictors of disease remission.

BACKGROUND: Although thymectomy is a standard practice of care in patients with myasthenia gravis, the best approach to thymic resection remains controversial. This study was conducted to assess the effect of maximal resection on neurologic outcome and identify predictors of disease remission. METHODS: Data of 78 myasthenic patients who underwent modified maximal thymectomy during a 17-year period were retrospectively analyzed. The primary study end point was the achievement of complete remission. Separate analysis was performed for thymoma and nonthymoma patients regarding the factors predicting the neurologic outcome. RESULTS: No patients died perioperatively. Surgical morbidity was 7.7%. The rate of postoperative myasthenic crisis was 3.8%. Thymoma and nonthymoma patients experienced comparable complete stable remission prediction (74.5% vs 85.7% at 15 years; p = 0.632). The absence of steroids in the preoperative medical treatment was statistically related to the prediction for complete stable remission in both thymoma (95% confidence interval [CI], 2.687 to 339.182, p = 0.006) and nonthymoma patients (95% CI, 1.607 to 19.183; p = 0.007) in multivariate analysis. In thymomatous myasthenia gravis, there was a statistically significant association between disease remission and the World Health Organization (WHO) histologic classification (95% CI, 0.262 to 0.827; p = 0.009). CONCLUSIONS: Maximal resections are recommended in myasthenic patients. Disease severity represents the prime determinant of the neurologic outcome after thymectomy. The neurologic outcome in patients after thymectomy may be statistically associated with the WHO classification subtypes but not necessarily with the aggressiveness of these tumors.

Low incidence of bronchopleural fistula after pneumonectomy for lung cancer.

Bronchopleural fistula (BPF) after pneumonectomy for NSCLC remains a highly morbid complication. We examined possible factors including the surgical techniques associated with BPF development. From 221 pneumonectomies for NSCLC, bronchial stump closure was mechanically performed in 192 patients and manually in the remaining 29. In all right-sided pneumonectomies mechanical closure was performed with associated stump coverage. In 114/130 left-sided procedures where mechanical closure was selected, bronchial stump remained uncovered. In the remaining 16 left-sided cases where manual stump closure was selectively performed, the stump was covered utilizing various tissues. Risk factors were classified into preoperative, intra-operative and postoperative. Five patients (2.3%) developed BPF. Univariate analysis revealed peri-operative transfusion, respiratory infection at the time of presentation, neoadjuvant therapy, right-sided pneumonectomy, manual type of bronchial closure, days of postoperative hospitalization and mechanical ventilation as significant risk factors for BPF development. Multivariate analysis followed revealing preoperative respiratory infection and right pneumonectomy as the only independent risk factors. In our series, a selected stump coverage policy showed a low incidence of BPF development. Mechanical stapling was superior to manual closure, although not as an independent factor. Early recognition of possible risk factors associated with fistula development is of paramount importance.

Current role of surgery in small cell lung carcinoma.

Small cell lung carcinoma represents 15-20% of lung cancer. Is is characterized by rapid growth and early disseminated disease with poor outcome. For many years surgery was considered a contraindication in Small Cell Lung Cancer (SCLC) since radiotherapy and chemoradiotherapy were found to be more efficient in the management of these patients. Never the less some surgeons continue to be in favor of surgery as part of a combined modality treatment in patients with SCLC. The reevaluation of the role of surgery in this group of patients is based on clinical data indicating a much better prognosis in selected patients with limited disease (T1-2, N0, M0), the high rate of local recurrence after chemoradiotherapy with surgery considered eventually more efficient in the local control of the disease and the fact that surgery is the most accurate tool to access the response to chemotherapy, identify carcinoids misdiagnosed as SCLC and treat the Non Small Cell Lung Cancer component of mixed tumors. Performing surgery for local disease SCLC requires a complete preoperative assessment to exclude the presence of nodal involvement. In stage I surgery must always be followed by adjuvant chemotherapy, while in stage II and III surgery must be planned only in the context of clinical trials and after a pathologic response to induction chemoradiotherapy has been confirmed. Prophylactic cranial irradiation should be used to reduce the incidence of brain metastasis.

Modified maximal thymectomy for thymic epithelial tumors: predictors of survival and neurological outcome in patients with thymomatous myasthenia gravis.

BACKGROUND: Thymic epithelial tumors are characterized by slow growth and variable malignant behavior. We present our experience on the surgical management of these tumors. MATERIALS AND METHODS: We conducted a retrospective analysis of patients with thymomas undergoing modified maximal thymectomy over a period of 16 years. Evaluated parameters included gender, age, Masaoka stage, WHO histology, R0 resection, myasthenia gravis, and adjuvant radiotherapy. In thymoma-associated myasthenia gravis, further analysis was made according the Osserman stage, the time from myasthenia diagnosis to thymectomy, and the steroid treatment. End points were survival for the total study group and achievement of complete stable remission (CSR) in patients with myasthenia gravis. RESULTS: The study group consisted of 15 male and 24 female patients. There was no perioperative mortality. Overall survival was 91.6% and 75.1% at 5 and 10 years. Univariate analysis identified the following predictors of survival: myasthenia (P < 0.001), Masaoka stage (P < 0.001), R0 resection (P < 0.001), and WHO histology (P = 0.007). Only the WHO histology was an independent predictor of survival in multivariate analysis (P = 0.003). Myasthenia patients had CSR prediction of 51.9% and 75.9% at 10 and 15 years. Preoperative steroid treatment (P = 0.007) and WHO histology (P = 0.021) were independent predictors of CSR on multivariate analysis. CONCLUSIONS: Modified maximal thymectomy is safe and efficient in the treatment of thymomas. WHO histology is the prime determinant of tumor aggressiveness and patient survival. Paraneoplastic myasthenia gravis and its outcome after thymectomy is significantly correlated with the WHO classification subtypes; however, lower CSR rates are not necessarily associated with more aggressive histological subgroups.

Primary aortoesophageal fistula due to thoracic aortic aneurysm: successful surgical treatment.

Aortoesophageal fistula is a rare emergency that presents a real challenge for cardiothoracic surgeons. There have been few reports of survivors. We present the case of a 70-year-old man with aortoesophageal fistula, mediastinal abscess, and severe septicemia consequent to esophageal erosion and rupture of a chronic degenerative descending thoracic aortic aneurysm. The patient underwent successful surgical treatment by aorto-aortic bypass and bipolar esophageal exclusion in conjunction with a cervical esophagostomy and a feeding gastrostomy. The pleural cavity was copiously irrigated and drained. Three months later, a retrosternal gastric bypass operation was performed successfully. The patient's 6-month follow-up examination revealed no problems.